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Late-week discharges to home after CRC surgery prone to readmission
BOSTON – The day of the week a patient is discharged from the hospital may have an impact the likelihood of readmission.
Patients discharged home from the hospital on a Thursday after colorectal cancer surgery are more likely to be readmitted within 30 days than those discharged on any other day of the week, investigators found.
In contrast, there were no significant day-dependent differences in readmission rates among patients discharged to a skilled nursing facility or acute rehabilitation program, although patients admitted to clinical facilities had higher overall readmission rates, reported Anna Gustin and coinvestigators at the Levine Cancer Institute at the Carolinas Medical Center in Charlotte, N.C.
“For a patient discharged on a Thursday, if you’re going to get an infection, it’s going to be probably during the weekend, when it’s difficult to contact your primary physician, and when other resources are not as readily available,” said Ms. Gustin, who conducts epidemiologic research at Levine Cancer Center and is also a pre-med student and Japanese major at Wake Forest University in Winston-Salem, N.C.
In a study presented in a poster session at the annual Society of Surgical Oncology Cancer Symposium, Ms. Gustin and her coauthors looked at factors influencing readmission rates among patients undergoing surgery for primary, nonmetastatic colorectal cancer resections.
They drew on the to evaluate outcomes for 93,04 SEER-(Surveillance, Epidemiology, and End Results) Medicare database seven patients aged 66 years and older treated for primary colorectal cancer from 1998 through 2009.
They looked at potential contributing factors such as patient demographics, socioeconomic status, length of stay, days of admission and discharge, and discharge setting (home or clinical facility).
They use multivariate logistic regression models to analyze readmission rates at 14 and 30 days after initial discharge.
Focusing on home discharges, they found that as the week progressed, there was a significant likelihood that a patient discharged home would be readmitted (P less then .001 by chi-square and Cochran-Armitage tests). As noted before, the highest rate of readmission was for patients discharged on Thursday, at 12.4%, compared with 10.1% for patients discharged on Sunday, the discharge day least likely to be associated with rehospitalization.
In multivariate analysis, factors significantly associated with risk for 30-day readmission included male vs. female (hazard ratio, 1.16), black vs. other race (HR, 1.22), length of stay 5, 6-7, or 8-10 vs. 12 or more days (HR, 0.48, 0.59, 0.77, respectively), Charlson comorbidity index score 0, 1 or 3 vs. 3 (HR, 0.59, 0.73, 0.82, respectively), and home discharge vs. other (HR, 0.66; all above comparisons significant as shown by 95% confidence intervals).
The authors concluded that although home discharge itself reduces the likelihood of readmission, “improvements in preparing patients for discharge to home are needed. Additional outpatient interventions could rescue patients from readmission.”
They also suggested reexamining staffing policies and weekend availability of resources for patients, and call for addressing disparities in readmissions based on race, sex, length of stay, and comorbidities.
The study was internally supported. The authors reported having no relevant disclosures.
BOSTON – The day of the week a patient is discharged from the hospital may have an impact the likelihood of readmission.
Patients discharged home from the hospital on a Thursday after colorectal cancer surgery are more likely to be readmitted within 30 days than those discharged on any other day of the week, investigators found.
In contrast, there were no significant day-dependent differences in readmission rates among patients discharged to a skilled nursing facility or acute rehabilitation program, although patients admitted to clinical facilities had higher overall readmission rates, reported Anna Gustin and coinvestigators at the Levine Cancer Institute at the Carolinas Medical Center in Charlotte, N.C.
“For a patient discharged on a Thursday, if you’re going to get an infection, it’s going to be probably during the weekend, when it’s difficult to contact your primary physician, and when other resources are not as readily available,” said Ms. Gustin, who conducts epidemiologic research at Levine Cancer Center and is also a pre-med student and Japanese major at Wake Forest University in Winston-Salem, N.C.
In a study presented in a poster session at the annual Society of Surgical Oncology Cancer Symposium, Ms. Gustin and her coauthors looked at factors influencing readmission rates among patients undergoing surgery for primary, nonmetastatic colorectal cancer resections.
They drew on the to evaluate outcomes for 93,04 SEER-(Surveillance, Epidemiology, and End Results) Medicare database seven patients aged 66 years and older treated for primary colorectal cancer from 1998 through 2009.
They looked at potential contributing factors such as patient demographics, socioeconomic status, length of stay, days of admission and discharge, and discharge setting (home or clinical facility).
They use multivariate logistic regression models to analyze readmission rates at 14 and 30 days after initial discharge.
Focusing on home discharges, they found that as the week progressed, there was a significant likelihood that a patient discharged home would be readmitted (P less then .001 by chi-square and Cochran-Armitage tests). As noted before, the highest rate of readmission was for patients discharged on Thursday, at 12.4%, compared with 10.1% for patients discharged on Sunday, the discharge day least likely to be associated with rehospitalization.
In multivariate analysis, factors significantly associated with risk for 30-day readmission included male vs. female (hazard ratio, 1.16), black vs. other race (HR, 1.22), length of stay 5, 6-7, or 8-10 vs. 12 or more days (HR, 0.48, 0.59, 0.77, respectively), Charlson comorbidity index score 0, 1 or 3 vs. 3 (HR, 0.59, 0.73, 0.82, respectively), and home discharge vs. other (HR, 0.66; all above comparisons significant as shown by 95% confidence intervals).
The authors concluded that although home discharge itself reduces the likelihood of readmission, “improvements in preparing patients for discharge to home are needed. Additional outpatient interventions could rescue patients from readmission.”
They also suggested reexamining staffing policies and weekend availability of resources for patients, and call for addressing disparities in readmissions based on race, sex, length of stay, and comorbidities.
The study was internally supported. The authors reported having no relevant disclosures.
BOSTON – The day of the week a patient is discharged from the hospital may have an impact the likelihood of readmission.
Patients discharged home from the hospital on a Thursday after colorectal cancer surgery are more likely to be readmitted within 30 days than those discharged on any other day of the week, investigators found.
In contrast, there were no significant day-dependent differences in readmission rates among patients discharged to a skilled nursing facility or acute rehabilitation program, although patients admitted to clinical facilities had higher overall readmission rates, reported Anna Gustin and coinvestigators at the Levine Cancer Institute at the Carolinas Medical Center in Charlotte, N.C.
“For a patient discharged on a Thursday, if you’re going to get an infection, it’s going to be probably during the weekend, when it’s difficult to contact your primary physician, and when other resources are not as readily available,” said Ms. Gustin, who conducts epidemiologic research at Levine Cancer Center and is also a pre-med student and Japanese major at Wake Forest University in Winston-Salem, N.C.
In a study presented in a poster session at the annual Society of Surgical Oncology Cancer Symposium, Ms. Gustin and her coauthors looked at factors influencing readmission rates among patients undergoing surgery for primary, nonmetastatic colorectal cancer resections.
They drew on the to evaluate outcomes for 93,04 SEER-(Surveillance, Epidemiology, and End Results) Medicare database seven patients aged 66 years and older treated for primary colorectal cancer from 1998 through 2009.
They looked at potential contributing factors such as patient demographics, socioeconomic status, length of stay, days of admission and discharge, and discharge setting (home or clinical facility).
They use multivariate logistic regression models to analyze readmission rates at 14 and 30 days after initial discharge.
Focusing on home discharges, they found that as the week progressed, there was a significant likelihood that a patient discharged home would be readmitted (P less then .001 by chi-square and Cochran-Armitage tests). As noted before, the highest rate of readmission was for patients discharged on Thursday, at 12.4%, compared with 10.1% for patients discharged on Sunday, the discharge day least likely to be associated with rehospitalization.
In multivariate analysis, factors significantly associated with risk for 30-day readmission included male vs. female (hazard ratio, 1.16), black vs. other race (HR, 1.22), length of stay 5, 6-7, or 8-10 vs. 12 or more days (HR, 0.48, 0.59, 0.77, respectively), Charlson comorbidity index score 0, 1 or 3 vs. 3 (HR, 0.59, 0.73, 0.82, respectively), and home discharge vs. other (HR, 0.66; all above comparisons significant as shown by 95% confidence intervals).
The authors concluded that although home discharge itself reduces the likelihood of readmission, “improvements in preparing patients for discharge to home are needed. Additional outpatient interventions could rescue patients from readmission.”
They also suggested reexamining staffing policies and weekend availability of resources for patients, and call for addressing disparities in readmissions based on race, sex, length of stay, and comorbidities.
The study was internally supported. The authors reported having no relevant disclosures.
Key clinical point: Patients discharged home on a Thursday following surgery for primary colorectal cancer are more likely to be readmitted with 30 days than are patients discharged home on any other day of the week.
Major finding: The highest rate of readmission was for patients discharged on Thursday, at 12.4%, compared with lowest rate of 10.1% for patients discharged on Sunday.
Data source: Retrospective SEER-Medicare database review of records on 93,047 patients treated for colorectal cancer.
Disclosures: The study was internally supported. The authors reported having no relevant disclosures.
Antibiotic-resistant infections remain a persistent threat
One in every seven infections in acute care hospitals related to catheters and surgeries was caused by antibiotic-resistant bacteria. In long-term acute care hospitals, that number increased to one in four.
Those are key findings from a study published March 3 in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report that is the first to combine national data on antibiotic-resistant (AR) bacteria threats with progress on health care–associated infections (HAIs).
“Antibiotic resistance threatens to return us to a time when a simple infection could kill,” CDC Director Thomas Frieden said during a March 3 telebriefing. “The more people who get infected with resistant bacteria, the more people who suffer complications, the more who, tragically, may die from preventable infections. On any given day about one in 25 hospitalized patients has at least one health care–associated infection that they didn’t come in with. No one should get sick when they’re trying to get well.”
For the study, researchers led by Dr. Clifford McDonald of the CDC’s Division of Healthcare Quality Promotion, collected data on specific infections that were reported to the National Healthcare Safety Network in 2014 by approximately 4,000 short-term acute care hospitals, 501 long-term acute care hospitals, and 1,135 inpatient rehabilitation facilities in all 50 states (MMWR. 2016 Mar 3. doi: 10.15585/mmwr.mm6509e1er). Next, they determined the proportions of AR pathogens and HAIs caused by any of six resistant bacteria highlighted by the CDC in 2013 as urgent or serious threats: CRE (carbapenem-resistant Enterobacteriaceae), MRSA (methicillin-resistant Staphylococcus aureus), ESBL-producing Enterobacteriaceae (extended-spectrum beta-lactamases), VRE (vancomycin-resistant enterococci), multidrug-resistant pseudomonas, and multidrug-resistant Acinetobacter.
The researchers found that, compared with historical data from 5-8 years earlier, central line–associated bloodstream infections decreased by 50% and surgical site infections (SSIs) by 17% in 2014.
“There is encouraging news here,” Dr. Frieden said. “Doctors, nurses, hospitals, health care systems and other partners have made progress preventing some health care–associated infections.” However, the study found that one in six remaining central line-associated bloodstream infections were caused by urgent or serious antibiotic-resistant bacteria, while one in seven remaining surgical site infections were caused by urgent or serious antibiotic-resistant bacteria.
While catheter-associated urinary tract infections appear unchanged from baseline, there have been recent decreases, according to the study. In addition, C. difficile infections in hospitals decreased 8% between 2011 and 2014.
Dr. McDonald and his associates determined that in 2014, one in seven infections in acute care hospitals related to catheters and surgeries was caused by one of the six antibiotic-resistance threat bacteria, “which is deeply concerning,” Dr. Frieden said. That number increased to one in four infections in long-term acute care hospitals, a proportion that he characterized as “chilling.”
The CDC recommends three strategies that doctors, nurses, and other health care providers should take with every patient, to prevent HAIs and stop the spread of antibiotic resistance:
• Prevent the spread of bacteria between patients. Dr. Peter Pronovost, who participated in the telebriefing, said that he and his associates at Johns Hopkins University in Baltimore “do this by practicing good hand hygiene techniques by wearing sterile equipment when inserting lines.”
• Prevent surgery-related infections and/or placement of a catheter. “Check catheters frequently and remove them when you no longer need them,” advised Dr. Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins. “Ask if you actually need them before you even place them.”
• Improve antibiotic use through stewardship. This means using “the right antibiotics for the right duration,” Dr. Pronovost said. “Antibiotics could be lifesaving and are necessary for critically ill patients, especially those with septic shock. But these antibiotics need to be adjusted based on lab results and new information about the organisms that are causing these infections. Forty-eight hours after antibiotics are initiated, take a ‘time out.’ Perform a brief but focused assessment to determine if antibiotic therapy is still needed, or if it should be refined. A common mistake we make is to continue vancomycin when there is no presence of MRSA. We often tell our staff at Johns Hopkins, ‘if it doesn’t grow, let it go.’ ”
Dr. Frieden concluded his remarks by noting that physicians and other clinicians on the front lines “need support of their facility leadership,” to prevent HAIs. “Health care facilities, CEOs, and administrators are a major part of the solution. It’s important that they make a priority of infection prevention, sepsis prevention, and antibiotic stewardship. Know your facility’s data and target prevention efforts to ensure improvements in patient safety.”
One in every seven infections in acute care hospitals related to catheters and surgeries was caused by antibiotic-resistant bacteria. In long-term acute care hospitals, that number increased to one in four.
Those are key findings from a study published March 3 in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report that is the first to combine national data on antibiotic-resistant (AR) bacteria threats with progress on health care–associated infections (HAIs).
“Antibiotic resistance threatens to return us to a time when a simple infection could kill,” CDC Director Thomas Frieden said during a March 3 telebriefing. “The more people who get infected with resistant bacteria, the more people who suffer complications, the more who, tragically, may die from preventable infections. On any given day about one in 25 hospitalized patients has at least one health care–associated infection that they didn’t come in with. No one should get sick when they’re trying to get well.”
For the study, researchers led by Dr. Clifford McDonald of the CDC’s Division of Healthcare Quality Promotion, collected data on specific infections that were reported to the National Healthcare Safety Network in 2014 by approximately 4,000 short-term acute care hospitals, 501 long-term acute care hospitals, and 1,135 inpatient rehabilitation facilities in all 50 states (MMWR. 2016 Mar 3. doi: 10.15585/mmwr.mm6509e1er). Next, they determined the proportions of AR pathogens and HAIs caused by any of six resistant bacteria highlighted by the CDC in 2013 as urgent or serious threats: CRE (carbapenem-resistant Enterobacteriaceae), MRSA (methicillin-resistant Staphylococcus aureus), ESBL-producing Enterobacteriaceae (extended-spectrum beta-lactamases), VRE (vancomycin-resistant enterococci), multidrug-resistant pseudomonas, and multidrug-resistant Acinetobacter.
The researchers found that, compared with historical data from 5-8 years earlier, central line–associated bloodstream infections decreased by 50% and surgical site infections (SSIs) by 17% in 2014.
“There is encouraging news here,” Dr. Frieden said. “Doctors, nurses, hospitals, health care systems and other partners have made progress preventing some health care–associated infections.” However, the study found that one in six remaining central line-associated bloodstream infections were caused by urgent or serious antibiotic-resistant bacteria, while one in seven remaining surgical site infections were caused by urgent or serious antibiotic-resistant bacteria.
While catheter-associated urinary tract infections appear unchanged from baseline, there have been recent decreases, according to the study. In addition, C. difficile infections in hospitals decreased 8% between 2011 and 2014.
Dr. McDonald and his associates determined that in 2014, one in seven infections in acute care hospitals related to catheters and surgeries was caused by one of the six antibiotic-resistance threat bacteria, “which is deeply concerning,” Dr. Frieden said. That number increased to one in four infections in long-term acute care hospitals, a proportion that he characterized as “chilling.”
The CDC recommends three strategies that doctors, nurses, and other health care providers should take with every patient, to prevent HAIs and stop the spread of antibiotic resistance:
• Prevent the spread of bacteria between patients. Dr. Peter Pronovost, who participated in the telebriefing, said that he and his associates at Johns Hopkins University in Baltimore “do this by practicing good hand hygiene techniques by wearing sterile equipment when inserting lines.”
• Prevent surgery-related infections and/or placement of a catheter. “Check catheters frequently and remove them when you no longer need them,” advised Dr. Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins. “Ask if you actually need them before you even place them.”
• Improve antibiotic use through stewardship. This means using “the right antibiotics for the right duration,” Dr. Pronovost said. “Antibiotics could be lifesaving and are necessary for critically ill patients, especially those with septic shock. But these antibiotics need to be adjusted based on lab results and new information about the organisms that are causing these infections. Forty-eight hours after antibiotics are initiated, take a ‘time out.’ Perform a brief but focused assessment to determine if antibiotic therapy is still needed, or if it should be refined. A common mistake we make is to continue vancomycin when there is no presence of MRSA. We often tell our staff at Johns Hopkins, ‘if it doesn’t grow, let it go.’ ”
Dr. Frieden concluded his remarks by noting that physicians and other clinicians on the front lines “need support of their facility leadership,” to prevent HAIs. “Health care facilities, CEOs, and administrators are a major part of the solution. It’s important that they make a priority of infection prevention, sepsis prevention, and antibiotic stewardship. Know your facility’s data and target prevention efforts to ensure improvements in patient safety.”
One in every seven infections in acute care hospitals related to catheters and surgeries was caused by antibiotic-resistant bacteria. In long-term acute care hospitals, that number increased to one in four.
Those are key findings from a study published March 3 in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report that is the first to combine national data on antibiotic-resistant (AR) bacteria threats with progress on health care–associated infections (HAIs).
“Antibiotic resistance threatens to return us to a time when a simple infection could kill,” CDC Director Thomas Frieden said during a March 3 telebriefing. “The more people who get infected with resistant bacteria, the more people who suffer complications, the more who, tragically, may die from preventable infections. On any given day about one in 25 hospitalized patients has at least one health care–associated infection that they didn’t come in with. No one should get sick when they’re trying to get well.”
For the study, researchers led by Dr. Clifford McDonald of the CDC’s Division of Healthcare Quality Promotion, collected data on specific infections that were reported to the National Healthcare Safety Network in 2014 by approximately 4,000 short-term acute care hospitals, 501 long-term acute care hospitals, and 1,135 inpatient rehabilitation facilities in all 50 states (MMWR. 2016 Mar 3. doi: 10.15585/mmwr.mm6509e1er). Next, they determined the proportions of AR pathogens and HAIs caused by any of six resistant bacteria highlighted by the CDC in 2013 as urgent or serious threats: CRE (carbapenem-resistant Enterobacteriaceae), MRSA (methicillin-resistant Staphylococcus aureus), ESBL-producing Enterobacteriaceae (extended-spectrum beta-lactamases), VRE (vancomycin-resistant enterococci), multidrug-resistant pseudomonas, and multidrug-resistant Acinetobacter.
The researchers found that, compared with historical data from 5-8 years earlier, central line–associated bloodstream infections decreased by 50% and surgical site infections (SSIs) by 17% in 2014.
“There is encouraging news here,” Dr. Frieden said. “Doctors, nurses, hospitals, health care systems and other partners have made progress preventing some health care–associated infections.” However, the study found that one in six remaining central line-associated bloodstream infections were caused by urgent or serious antibiotic-resistant bacteria, while one in seven remaining surgical site infections were caused by urgent or serious antibiotic-resistant bacteria.
While catheter-associated urinary tract infections appear unchanged from baseline, there have been recent decreases, according to the study. In addition, C. difficile infections in hospitals decreased 8% between 2011 and 2014.
Dr. McDonald and his associates determined that in 2014, one in seven infections in acute care hospitals related to catheters and surgeries was caused by one of the six antibiotic-resistance threat bacteria, “which is deeply concerning,” Dr. Frieden said. That number increased to one in four infections in long-term acute care hospitals, a proportion that he characterized as “chilling.”
The CDC recommends three strategies that doctors, nurses, and other health care providers should take with every patient, to prevent HAIs and stop the spread of antibiotic resistance:
• Prevent the spread of bacteria between patients. Dr. Peter Pronovost, who participated in the telebriefing, said that he and his associates at Johns Hopkins University in Baltimore “do this by practicing good hand hygiene techniques by wearing sterile equipment when inserting lines.”
• Prevent surgery-related infections and/or placement of a catheter. “Check catheters frequently and remove them when you no longer need them,” advised Dr. Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins. “Ask if you actually need them before you even place them.”
• Improve antibiotic use through stewardship. This means using “the right antibiotics for the right duration,” Dr. Pronovost said. “Antibiotics could be lifesaving and are necessary for critically ill patients, especially those with septic shock. But these antibiotics need to be adjusted based on lab results and new information about the organisms that are causing these infections. Forty-eight hours after antibiotics are initiated, take a ‘time out.’ Perform a brief but focused assessment to determine if antibiotic therapy is still needed, or if it should be refined. A common mistake we make is to continue vancomycin when there is no presence of MRSA. We often tell our staff at Johns Hopkins, ‘if it doesn’t grow, let it go.’ ”
Dr. Frieden concluded his remarks by noting that physicians and other clinicians on the front lines “need support of their facility leadership,” to prevent HAIs. “Health care facilities, CEOs, and administrators are a major part of the solution. It’s important that they make a priority of infection prevention, sepsis prevention, and antibiotic stewardship. Know your facility’s data and target prevention efforts to ensure improvements in patient safety.”
FROM MMWR
HIV not a risk factor for postappendectomy complications
JACKSONVILLE, FLA. – Patients who have HIV are at no greater risk of complications from appendectomy than are non-HIV patients according to an analysis of cases in a national surgical database presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Dr. Michael C. Smith of the State University of New York, Brooklyn, explained why he and his colleagues felt it was time to update the literature on HIV and surgery. “Much of the literature on appendectomy in the setting of HIV is either from the early 1990s or elsewhere in the world, and it shows greatly increased complication rates in these patients,” he said.
The analysis queried the Nationwide Inpatient Sample (NIS) database for all patients who had acute appendicitis and appendectomy during 2005-2012. The analysis included patients who had both open and laparoscopic appendectomy, and compared the HIV group that did not have AIDS with the non-HIV group, Dr. Smith said. The population with AIDS, along with patients who had interval appendectomies after appendicitis, were excluded.
The study looked at 821 patients with HIV and 338,425 patients without HIV as controls.
“The only significant difference we found between the two groups was hospital length of stay, which differed by about three-quarters of a day,” Dr. Smith said. Patients with HIV spent on average 3.8 days in the hospital after appendectomy vs. 3 days for non-HIV patients. “Other complication rates were nonsignificant by our study,” he said.
The average total charge for HIV patients was also higher, $33,350 vs. $30,714, the analysis showed.
Dr. Smith acknowledged some limitations in using the NIS database, most notably that the data were from index hospitalizations only. “So we probably did not capture people who returned to the hospital on postoperative day 3, 4, and 5 after they were discharged home,” he said. “Therefore, prospective studies are needed to validate these results.”
He also said that the study did not differentiate between operations for perforated and nonperforated appendix, and he and his coresearchers could not determine why the HIV population had longer hospital stays.
Dr. Smith and coauthors had no financial relationships to disclose.
JACKSONVILLE, FLA. – Patients who have HIV are at no greater risk of complications from appendectomy than are non-HIV patients according to an analysis of cases in a national surgical database presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Dr. Michael C. Smith of the State University of New York, Brooklyn, explained why he and his colleagues felt it was time to update the literature on HIV and surgery. “Much of the literature on appendectomy in the setting of HIV is either from the early 1990s or elsewhere in the world, and it shows greatly increased complication rates in these patients,” he said.
The analysis queried the Nationwide Inpatient Sample (NIS) database for all patients who had acute appendicitis and appendectomy during 2005-2012. The analysis included patients who had both open and laparoscopic appendectomy, and compared the HIV group that did not have AIDS with the non-HIV group, Dr. Smith said. The population with AIDS, along with patients who had interval appendectomies after appendicitis, were excluded.
The study looked at 821 patients with HIV and 338,425 patients without HIV as controls.
“The only significant difference we found between the two groups was hospital length of stay, which differed by about three-quarters of a day,” Dr. Smith said. Patients with HIV spent on average 3.8 days in the hospital after appendectomy vs. 3 days for non-HIV patients. “Other complication rates were nonsignificant by our study,” he said.
The average total charge for HIV patients was also higher, $33,350 vs. $30,714, the analysis showed.
Dr. Smith acknowledged some limitations in using the NIS database, most notably that the data were from index hospitalizations only. “So we probably did not capture people who returned to the hospital on postoperative day 3, 4, and 5 after they were discharged home,” he said. “Therefore, prospective studies are needed to validate these results.”
He also said that the study did not differentiate between operations for perforated and nonperforated appendix, and he and his coresearchers could not determine why the HIV population had longer hospital stays.
Dr. Smith and coauthors had no financial relationships to disclose.
JACKSONVILLE, FLA. – Patients who have HIV are at no greater risk of complications from appendectomy than are non-HIV patients according to an analysis of cases in a national surgical database presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Dr. Michael C. Smith of the State University of New York, Brooklyn, explained why he and his colleagues felt it was time to update the literature on HIV and surgery. “Much of the literature on appendectomy in the setting of HIV is either from the early 1990s or elsewhere in the world, and it shows greatly increased complication rates in these patients,” he said.
The analysis queried the Nationwide Inpatient Sample (NIS) database for all patients who had acute appendicitis and appendectomy during 2005-2012. The analysis included patients who had both open and laparoscopic appendectomy, and compared the HIV group that did not have AIDS with the non-HIV group, Dr. Smith said. The population with AIDS, along with patients who had interval appendectomies after appendicitis, were excluded.
The study looked at 821 patients with HIV and 338,425 patients without HIV as controls.
“The only significant difference we found between the two groups was hospital length of stay, which differed by about three-quarters of a day,” Dr. Smith said. Patients with HIV spent on average 3.8 days in the hospital after appendectomy vs. 3 days for non-HIV patients. “Other complication rates were nonsignificant by our study,” he said.
The average total charge for HIV patients was also higher, $33,350 vs. $30,714, the analysis showed.
Dr. Smith acknowledged some limitations in using the NIS database, most notably that the data were from index hospitalizations only. “So we probably did not capture people who returned to the hospital on postoperative day 3, 4, and 5 after they were discharged home,” he said. “Therefore, prospective studies are needed to validate these results.”
He also said that the study did not differentiate between operations for perforated and nonperforated appendix, and he and his coresearchers could not determine why the HIV population had longer hospital stays.
Dr. Smith and coauthors had no financial relationships to disclose.
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Patients who have HIV are at no greater risk of complications from appendectomy than are non-HIV patients.
Major finding: Risk of death and complications were similar across both groups, although hospital stays were about 26% longer and cost about 10% more for patients with HIV.
Data source: Query of Nationwide Inpatient Sample (NIS) database during 2005-2012 of 812 HIV and 338,425 non-HIV patients who had appendectomy for acute appendicitis.
Disclosures: The study authors reported having no financial disclosures.
Periop statins don’t prevent acute kidney injury after cardiac surgery
ORLANDO – Statins administered perioperatively offered no protection against acute kidney injury following cardiac surgery, according to new results of a 5-year randomized clinical trial.
The findings held true whether or not patients were naive to statins; serum creatinine levels actually increased significantly more for statin-naive patients given atorvastatin than those given placebo.
The study was stopped early for patients naive to statins because increased acute kidney injury was seen in those patients who had chronic kidney disease (eGFR less than 60 mL/min/1.73 m2), and was subsequently stopped early for futility for all patients.
“De novo initiation of daily perioperative atorvastatin treatment did not reduce the incidence of AKI or reduce the increase in serum creatinine concentration associated with cardiac surgery,” wrote Dr. Frederic T. Billings IV, professor of medicine at Vanderbilt University, Nashville, Tenn., and his collaborators. The findings (JAMA 2016 Feb 23. doi: 10.1001/jama.2016.0548) were published concurrently with his presentation at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.
In what Dr. Phil B. Fontanarosa, executive editor of JAMA and comoderator of the late-breaking trials session at the meeting, described as “really an elegant clinical trial,” Dr. Billings and his collaborators enrolled 615 patients over 5 years at Vanderbilt University Medical Center.
Patients undergoing elective coronary artery bypass grafting, valvular heart surgery, or ascending aortic surgery were eligible. Patients were excluded if they had prior statin intolerance, acute coronary syndrome, or liver dysfunction; were taking potent CYP3A4 inhibitors or cyclosporine; were receiving renal replacement therapy or had a kidney transplant; or were pregnant.
Both patients currently on a statin and patients naive to statins were recruited. Statin-naive patients received 80 mg atorvastatin the day before surgery, and then 40 mg of atorvastatin on the day of surgery and daily following surgery, or a matched placebo regimen.
Patients who were already on a statin received the study drug only on days that they would not have received a statin if treated according to the current standard of care. It was deemed unethical to allow those patients to receive placebo during and after surgery, since observational studies suggested that doing so might increase their potential for AKI.
For those patients already on a statin, this meant that they stayed on their usual regimen until the day of surgery, and then were randomized to receive either 80 mg of atorvastatin on the day of surgery and 40 mg of atorvastatin the day after surgery, or a matching placebo regimen.
For both groups, the study drug was given at least 3 hours before surgery on the day of surgery.
Randomization was stratified for prior statin use, for chronic kidney disease, and by history of diabetes. The 199 patients naive to statins and the 416 already on a statin were similar in demographic and health characteristics. Median age was 67 years, 188 (30.6%) were women; 202 participants (32.8%) had diabetes.
The primary outcome measure was diagnosis of AKI, defined as an increase of 0.3 mg/dL in serum creatinine, or beginning renal replacement therapy within 48 hours of surgery. Baseline serum creatinine was measured no more than 7 days prior to surgery.
AKI occurred in 64 of 308 patients (20.8%) in the atorvastatin group, and in 60 of 307 patients (19.5%) receiving placebo overall (P = .75). For those naive to statins, 21.6% of the atorvastatin group and 13.4% of the placebo group developed AKI (P = .15). Overall, 179 enrolled patients had CKD, and the incidence of AKI did not significantly differ in the atorvastatin and the placebo arms of this subgroup.
The subpopulation of participants with CKD who were statin naive (n = 36), however, saw an increased incidence of AKI with atorvastatin compared to placebo. AKI occurred in 9 of 17 patients (52.9%) given atorvastatin, and in 3 of 19 (15.8%) given placebo group (RR, 3.35[95% confidence interval 0.12 to 10.05]; P = .03). “It should be noted that the number of patients in this subgroup was particularly small, leading to a wide confidence interval and an increased chance of type 1 error,” said Dr. Billings.
Secondary outcome measures were maximum increase in creatinine concentration from baseline through postop day 2, delirium in the ICU, degree of myocardial injury, and incidence of postoperative pneumonia, atrial fibrillation, or stroke. Perioperative atorvastatin administration did not affect any of these endpoints.
The safety analysis showed no indications of increased risk of skeletal muscle or liver injury with perioperative atorvastatin use.
In the real world, “Most patients presenting for cardiac surgery … are already taking statins, and in the current study there was little evidence that continuation or withdrawal from statin treatment on the day of surgery and postoperative day 1 affects AKI,” wrote Dr. Billings and his coauthors.
Study limitations included its single-center design, and the use of AKI criteria that may not be sensitive to late-developing AKI. Also, for enrolled patients who were already on statins, statin exposure was not reduced in comparison with usual care.
After the presentation, Dr. Billings reported that the researchers also collected information about other biomarkers that may signal AKI, including IgM. He and his collaborators plan later publication of those data after a full analysis.
The National Institutes of Health and the Vanderbilt University Medical Center department of anesthesiology funded the study. Dr. Brown reported receiving grants from Shire Pharmaceuticals and New Haven Pharmaceuticals, and personal fees from Novartis Pharmaceuticals and Alnylam Pharmaceuticals. The other authors reported no conflicts of interest.
On Twitter @karioakes
ORLANDO – Statins administered perioperatively offered no protection against acute kidney injury following cardiac surgery, according to new results of a 5-year randomized clinical trial.
The findings held true whether or not patients were naive to statins; serum creatinine levels actually increased significantly more for statin-naive patients given atorvastatin than those given placebo.
The study was stopped early for patients naive to statins because increased acute kidney injury was seen in those patients who had chronic kidney disease (eGFR less than 60 mL/min/1.73 m2), and was subsequently stopped early for futility for all patients.
“De novo initiation of daily perioperative atorvastatin treatment did not reduce the incidence of AKI or reduce the increase in serum creatinine concentration associated with cardiac surgery,” wrote Dr. Frederic T. Billings IV, professor of medicine at Vanderbilt University, Nashville, Tenn., and his collaborators. The findings (JAMA 2016 Feb 23. doi: 10.1001/jama.2016.0548) were published concurrently with his presentation at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.
In what Dr. Phil B. Fontanarosa, executive editor of JAMA and comoderator of the late-breaking trials session at the meeting, described as “really an elegant clinical trial,” Dr. Billings and his collaborators enrolled 615 patients over 5 years at Vanderbilt University Medical Center.
Patients undergoing elective coronary artery bypass grafting, valvular heart surgery, or ascending aortic surgery were eligible. Patients were excluded if they had prior statin intolerance, acute coronary syndrome, or liver dysfunction; were taking potent CYP3A4 inhibitors or cyclosporine; were receiving renal replacement therapy or had a kidney transplant; or were pregnant.
Both patients currently on a statin and patients naive to statins were recruited. Statin-naive patients received 80 mg atorvastatin the day before surgery, and then 40 mg of atorvastatin on the day of surgery and daily following surgery, or a matched placebo regimen.
Patients who were already on a statin received the study drug only on days that they would not have received a statin if treated according to the current standard of care. It was deemed unethical to allow those patients to receive placebo during and after surgery, since observational studies suggested that doing so might increase their potential for AKI.
For those patients already on a statin, this meant that they stayed on their usual regimen until the day of surgery, and then were randomized to receive either 80 mg of atorvastatin on the day of surgery and 40 mg of atorvastatin the day after surgery, or a matching placebo regimen.
For both groups, the study drug was given at least 3 hours before surgery on the day of surgery.
Randomization was stratified for prior statin use, for chronic kidney disease, and by history of diabetes. The 199 patients naive to statins and the 416 already on a statin were similar in demographic and health characteristics. Median age was 67 years, 188 (30.6%) were women; 202 participants (32.8%) had diabetes.
The primary outcome measure was diagnosis of AKI, defined as an increase of 0.3 mg/dL in serum creatinine, or beginning renal replacement therapy within 48 hours of surgery. Baseline serum creatinine was measured no more than 7 days prior to surgery.
AKI occurred in 64 of 308 patients (20.8%) in the atorvastatin group, and in 60 of 307 patients (19.5%) receiving placebo overall (P = .75). For those naive to statins, 21.6% of the atorvastatin group and 13.4% of the placebo group developed AKI (P = .15). Overall, 179 enrolled patients had CKD, and the incidence of AKI did not significantly differ in the atorvastatin and the placebo arms of this subgroup.
The subpopulation of participants with CKD who were statin naive (n = 36), however, saw an increased incidence of AKI with atorvastatin compared to placebo. AKI occurred in 9 of 17 patients (52.9%) given atorvastatin, and in 3 of 19 (15.8%) given placebo group (RR, 3.35[95% confidence interval 0.12 to 10.05]; P = .03). “It should be noted that the number of patients in this subgroup was particularly small, leading to a wide confidence interval and an increased chance of type 1 error,” said Dr. Billings.
Secondary outcome measures were maximum increase in creatinine concentration from baseline through postop day 2, delirium in the ICU, degree of myocardial injury, and incidence of postoperative pneumonia, atrial fibrillation, or stroke. Perioperative atorvastatin administration did not affect any of these endpoints.
The safety analysis showed no indications of increased risk of skeletal muscle or liver injury with perioperative atorvastatin use.
In the real world, “Most patients presenting for cardiac surgery … are already taking statins, and in the current study there was little evidence that continuation or withdrawal from statin treatment on the day of surgery and postoperative day 1 affects AKI,” wrote Dr. Billings and his coauthors.
Study limitations included its single-center design, and the use of AKI criteria that may not be sensitive to late-developing AKI. Also, for enrolled patients who were already on statins, statin exposure was not reduced in comparison with usual care.
After the presentation, Dr. Billings reported that the researchers also collected information about other biomarkers that may signal AKI, including IgM. He and his collaborators plan later publication of those data after a full analysis.
The National Institutes of Health and the Vanderbilt University Medical Center department of anesthesiology funded the study. Dr. Brown reported receiving grants from Shire Pharmaceuticals and New Haven Pharmaceuticals, and personal fees from Novartis Pharmaceuticals and Alnylam Pharmaceuticals. The other authors reported no conflicts of interest.
On Twitter @karioakes
ORLANDO – Statins administered perioperatively offered no protection against acute kidney injury following cardiac surgery, according to new results of a 5-year randomized clinical trial.
The findings held true whether or not patients were naive to statins; serum creatinine levels actually increased significantly more for statin-naive patients given atorvastatin than those given placebo.
The study was stopped early for patients naive to statins because increased acute kidney injury was seen in those patients who had chronic kidney disease (eGFR less than 60 mL/min/1.73 m2), and was subsequently stopped early for futility for all patients.
“De novo initiation of daily perioperative atorvastatin treatment did not reduce the incidence of AKI or reduce the increase in serum creatinine concentration associated with cardiac surgery,” wrote Dr. Frederic T. Billings IV, professor of medicine at Vanderbilt University, Nashville, Tenn., and his collaborators. The findings (JAMA 2016 Feb 23. doi: 10.1001/jama.2016.0548) were published concurrently with his presentation at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.
In what Dr. Phil B. Fontanarosa, executive editor of JAMA and comoderator of the late-breaking trials session at the meeting, described as “really an elegant clinical trial,” Dr. Billings and his collaborators enrolled 615 patients over 5 years at Vanderbilt University Medical Center.
Patients undergoing elective coronary artery bypass grafting, valvular heart surgery, or ascending aortic surgery were eligible. Patients were excluded if they had prior statin intolerance, acute coronary syndrome, or liver dysfunction; were taking potent CYP3A4 inhibitors or cyclosporine; were receiving renal replacement therapy or had a kidney transplant; or were pregnant.
Both patients currently on a statin and patients naive to statins were recruited. Statin-naive patients received 80 mg atorvastatin the day before surgery, and then 40 mg of atorvastatin on the day of surgery and daily following surgery, or a matched placebo regimen.
Patients who were already on a statin received the study drug only on days that they would not have received a statin if treated according to the current standard of care. It was deemed unethical to allow those patients to receive placebo during and after surgery, since observational studies suggested that doing so might increase their potential for AKI.
For those patients already on a statin, this meant that they stayed on their usual regimen until the day of surgery, and then were randomized to receive either 80 mg of atorvastatin on the day of surgery and 40 mg of atorvastatin the day after surgery, or a matching placebo regimen.
For both groups, the study drug was given at least 3 hours before surgery on the day of surgery.
Randomization was stratified for prior statin use, for chronic kidney disease, and by history of diabetes. The 199 patients naive to statins and the 416 already on a statin were similar in demographic and health characteristics. Median age was 67 years, 188 (30.6%) were women; 202 participants (32.8%) had diabetes.
The primary outcome measure was diagnosis of AKI, defined as an increase of 0.3 mg/dL in serum creatinine, or beginning renal replacement therapy within 48 hours of surgery. Baseline serum creatinine was measured no more than 7 days prior to surgery.
AKI occurred in 64 of 308 patients (20.8%) in the atorvastatin group, and in 60 of 307 patients (19.5%) receiving placebo overall (P = .75). For those naive to statins, 21.6% of the atorvastatin group and 13.4% of the placebo group developed AKI (P = .15). Overall, 179 enrolled patients had CKD, and the incidence of AKI did not significantly differ in the atorvastatin and the placebo arms of this subgroup.
The subpopulation of participants with CKD who were statin naive (n = 36), however, saw an increased incidence of AKI with atorvastatin compared to placebo. AKI occurred in 9 of 17 patients (52.9%) given atorvastatin, and in 3 of 19 (15.8%) given placebo group (RR, 3.35[95% confidence interval 0.12 to 10.05]; P = .03). “It should be noted that the number of patients in this subgroup was particularly small, leading to a wide confidence interval and an increased chance of type 1 error,” said Dr. Billings.
Secondary outcome measures were maximum increase in creatinine concentration from baseline through postop day 2, delirium in the ICU, degree of myocardial injury, and incidence of postoperative pneumonia, atrial fibrillation, or stroke. Perioperative atorvastatin administration did not affect any of these endpoints.
The safety analysis showed no indications of increased risk of skeletal muscle or liver injury with perioperative atorvastatin use.
In the real world, “Most patients presenting for cardiac surgery … are already taking statins, and in the current study there was little evidence that continuation or withdrawal from statin treatment on the day of surgery and postoperative day 1 affects AKI,” wrote Dr. Billings and his coauthors.
Study limitations included its single-center design, and the use of AKI criteria that may not be sensitive to late-developing AKI. Also, for enrolled patients who were already on statins, statin exposure was not reduced in comparison with usual care.
After the presentation, Dr. Billings reported that the researchers also collected information about other biomarkers that may signal AKI, including IgM. He and his collaborators plan later publication of those data after a full analysis.
The National Institutes of Health and the Vanderbilt University Medical Center department of anesthesiology funded the study. Dr. Brown reported receiving grants from Shire Pharmaceuticals and New Haven Pharmaceuticals, and personal fees from Novartis Pharmaceuticals and Alnylam Pharmaceuticals. The other authors reported no conflicts of interest.
On Twitter @karioakes
AT THE CRITICAL CARE CONGRESS
Key clinical point: Perioperative atorvastatin did not protect against acute kidney injury after cardiac surgery.
Major finding: Acute kidney injury occurred in 64 of 308 patients (20.8%) in the atorvastatin group, and in 60 of 307 patients (19.5%) receiving placebo overall, a nonsignificant difference (P = .75).
Data source: Randomized, double-blinded, placebo-controlled trial of 615 adults who underwent cardiac surgery.
Disclosures: The National Institutes of Health and the Vanderbilt University Medical Center department of anesthesiology funded the study. Dr. Brown reported receiving grants from Shire Pharmaceuticals and New Haven Pharmaceuticals, and personal fees from Novartis Pharmaceuticals and Alnylam Pharmaceuticals. The other authors reported no conflicts of interest.
Adding azithromycin cuts postcesarean maternal infections
ATLANTA – Preincisional azithromycin reduced postcesarean maternal infections by half, and significantly cut postpartum trips to the hospital.
Given in tandem with standard prophylactic antibiotics, broad-spectrum intravenous azithromycin was highly effective, with a number needed to treat of 17 to prevent one postsurgical infection, and 43 to prevent one case of endometritis, Dr. Alan Tita reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.
“We also saw fewer maternal adverse events, and the protocol was safe for the newborn,” said Dr. Tita, a professor of obstetrics and gynecology at the University of Alabama, Birmingham.
The Study of Effectiveness and Safety of Azithromycin-Based Extended-Spectrum Prophylaxis to Prevent Post Cesarean Infection (C/SOAP) trial enrolled 2,013 women at 14 sites. All patients had singleton pregnancies of at least 24 weeks’ gestation. Patients had a cesarean after at least 4 hours of active labor or 4 hours after rupture of membranes.
All women received standard narrow-spectrum antibiotic prophylaxis with either cefazolin or clindamycin. They were randomized to either preincisional intravenous azithromycin 500 mg or saline placebo. The study had a pragmatic design, so skin disinfection was performed according to each facility’s standard protocol.
The primary outcome was a composite of endometritis, wound infection, abscess, pelvic septic thrombophlebitis, pyelonephritis, pneumonia, and meningitis. Secondary outcomes were maternal fever, unscheduled visits to health care providers (including hospital readmissions and emergency department visits), and death.
The neonatal outcome was a composite of death; primary or suspected sepsis; and serious neonatal morbidities, including respiratory distress syndrome, necrotizing enterocolitis, periventricular leukomalacia, intraventricular hemorrhage of grade 3 or higher, and bronchopulmonary dysplasia.
There were no baseline differences in the indication for cesarean or type of skin and uterine incision, Dr. Tita said. Most patients (88%) received their study drug before the incision.
The rate of the primary composite outcome was reduced by half in women who had azithromycin added to their cephalosporin prophylaxis (6% vs. 12%; relative risk, 0.49). Wound infection was cut by 65% (2.4% vs. 6.6%; RR, 0.35).
Azithromycin significantly improved the secondary maternal outcomes over placebo, including fever (5% vs. 8.2%; RR, 0.61), and readmissions or unscheduled visits (8.2% vs. 12.4%; RR, 0.66). The addition of azithromycin was associated with a significant decrease in the rate of severe maternal adverse events (1.5% vs. 2.9%).
Study site, obesity, and the type of skin prep did not significantly affect any of these outcomes, Dr. Tita noted.
The addition of azithromycin was safe for neonates. The composite neonatal safety outcome occurred in 14.3% of the treated group and 13.6% of the placebo group – not a significant difference. There were no differences in suspected or confirmed sepsis (11.8% vs. 12.5%), serious neonatal morbidities (4.4% vs. 3.4%), or NICU admission (16.8% vs. 17%), Dr. Tita reported.
There were no deaths in either mothers or infants. There were 11 maternal allergic reactions, five admissions to intensive care, and five suspected cardiac events.
When asked whether even brief systemic exposure to azithromycin could alter the fetal microbiome, Dr. Tita said he shares that concern but the answer is still unknown.
“We have collected additional information and specimens and we will be looking at these to try and answer this. We also hope to get funding to do a long-term evaluation of these kids. I will say that we collected adverse event data on them for 3 months and we did not see anything concerning, but I agree more needs to be done,” he said. “Having said that, azithromycin is something we already use quite a lot in obstetrics, and overall it has been shown to be safe for the newborn.”
The study was sponsored by the National Institute of Child Health and Human Development. Dr. Tita reported having no financial disclosures.
ATLANTA – Preincisional azithromycin reduced postcesarean maternal infections by half, and significantly cut postpartum trips to the hospital.
Given in tandem with standard prophylactic antibiotics, broad-spectrum intravenous azithromycin was highly effective, with a number needed to treat of 17 to prevent one postsurgical infection, and 43 to prevent one case of endometritis, Dr. Alan Tita reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.
“We also saw fewer maternal adverse events, and the protocol was safe for the newborn,” said Dr. Tita, a professor of obstetrics and gynecology at the University of Alabama, Birmingham.
The Study of Effectiveness and Safety of Azithromycin-Based Extended-Spectrum Prophylaxis to Prevent Post Cesarean Infection (C/SOAP) trial enrolled 2,013 women at 14 sites. All patients had singleton pregnancies of at least 24 weeks’ gestation. Patients had a cesarean after at least 4 hours of active labor or 4 hours after rupture of membranes.
All women received standard narrow-spectrum antibiotic prophylaxis with either cefazolin or clindamycin. They were randomized to either preincisional intravenous azithromycin 500 mg or saline placebo. The study had a pragmatic design, so skin disinfection was performed according to each facility’s standard protocol.
The primary outcome was a composite of endometritis, wound infection, abscess, pelvic septic thrombophlebitis, pyelonephritis, pneumonia, and meningitis. Secondary outcomes were maternal fever, unscheduled visits to health care providers (including hospital readmissions and emergency department visits), and death.
The neonatal outcome was a composite of death; primary or suspected sepsis; and serious neonatal morbidities, including respiratory distress syndrome, necrotizing enterocolitis, periventricular leukomalacia, intraventricular hemorrhage of grade 3 or higher, and bronchopulmonary dysplasia.
There were no baseline differences in the indication for cesarean or type of skin and uterine incision, Dr. Tita said. Most patients (88%) received their study drug before the incision.
The rate of the primary composite outcome was reduced by half in women who had azithromycin added to their cephalosporin prophylaxis (6% vs. 12%; relative risk, 0.49). Wound infection was cut by 65% (2.4% vs. 6.6%; RR, 0.35).
Azithromycin significantly improved the secondary maternal outcomes over placebo, including fever (5% vs. 8.2%; RR, 0.61), and readmissions or unscheduled visits (8.2% vs. 12.4%; RR, 0.66). The addition of azithromycin was associated with a significant decrease in the rate of severe maternal adverse events (1.5% vs. 2.9%).
Study site, obesity, and the type of skin prep did not significantly affect any of these outcomes, Dr. Tita noted.
The addition of azithromycin was safe for neonates. The composite neonatal safety outcome occurred in 14.3% of the treated group and 13.6% of the placebo group – not a significant difference. There were no differences in suspected or confirmed sepsis (11.8% vs. 12.5%), serious neonatal morbidities (4.4% vs. 3.4%), or NICU admission (16.8% vs. 17%), Dr. Tita reported.
There were no deaths in either mothers or infants. There were 11 maternal allergic reactions, five admissions to intensive care, and five suspected cardiac events.
When asked whether even brief systemic exposure to azithromycin could alter the fetal microbiome, Dr. Tita said he shares that concern but the answer is still unknown.
“We have collected additional information and specimens and we will be looking at these to try and answer this. We also hope to get funding to do a long-term evaluation of these kids. I will say that we collected adverse event data on them for 3 months and we did not see anything concerning, but I agree more needs to be done,” he said. “Having said that, azithromycin is something we already use quite a lot in obstetrics, and overall it has been shown to be safe for the newborn.”
The study was sponsored by the National Institute of Child Health and Human Development. Dr. Tita reported having no financial disclosures.
ATLANTA – Preincisional azithromycin reduced postcesarean maternal infections by half, and significantly cut postpartum trips to the hospital.
Given in tandem with standard prophylactic antibiotics, broad-spectrum intravenous azithromycin was highly effective, with a number needed to treat of 17 to prevent one postsurgical infection, and 43 to prevent one case of endometritis, Dr. Alan Tita reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.
“We also saw fewer maternal adverse events, and the protocol was safe for the newborn,” said Dr. Tita, a professor of obstetrics and gynecology at the University of Alabama, Birmingham.
The Study of Effectiveness and Safety of Azithromycin-Based Extended-Spectrum Prophylaxis to Prevent Post Cesarean Infection (C/SOAP) trial enrolled 2,013 women at 14 sites. All patients had singleton pregnancies of at least 24 weeks’ gestation. Patients had a cesarean after at least 4 hours of active labor or 4 hours after rupture of membranes.
All women received standard narrow-spectrum antibiotic prophylaxis with either cefazolin or clindamycin. They were randomized to either preincisional intravenous azithromycin 500 mg or saline placebo. The study had a pragmatic design, so skin disinfection was performed according to each facility’s standard protocol.
The primary outcome was a composite of endometritis, wound infection, abscess, pelvic septic thrombophlebitis, pyelonephritis, pneumonia, and meningitis. Secondary outcomes were maternal fever, unscheduled visits to health care providers (including hospital readmissions and emergency department visits), and death.
The neonatal outcome was a composite of death; primary or suspected sepsis; and serious neonatal morbidities, including respiratory distress syndrome, necrotizing enterocolitis, periventricular leukomalacia, intraventricular hemorrhage of grade 3 or higher, and bronchopulmonary dysplasia.
There were no baseline differences in the indication for cesarean or type of skin and uterine incision, Dr. Tita said. Most patients (88%) received their study drug before the incision.
The rate of the primary composite outcome was reduced by half in women who had azithromycin added to their cephalosporin prophylaxis (6% vs. 12%; relative risk, 0.49). Wound infection was cut by 65% (2.4% vs. 6.6%; RR, 0.35).
Azithromycin significantly improved the secondary maternal outcomes over placebo, including fever (5% vs. 8.2%; RR, 0.61), and readmissions or unscheduled visits (8.2% vs. 12.4%; RR, 0.66). The addition of azithromycin was associated with a significant decrease in the rate of severe maternal adverse events (1.5% vs. 2.9%).
Study site, obesity, and the type of skin prep did not significantly affect any of these outcomes, Dr. Tita noted.
The addition of azithromycin was safe for neonates. The composite neonatal safety outcome occurred in 14.3% of the treated group and 13.6% of the placebo group – not a significant difference. There were no differences in suspected or confirmed sepsis (11.8% vs. 12.5%), serious neonatal morbidities (4.4% vs. 3.4%), or NICU admission (16.8% vs. 17%), Dr. Tita reported.
There were no deaths in either mothers or infants. There were 11 maternal allergic reactions, five admissions to intensive care, and five suspected cardiac events.
When asked whether even brief systemic exposure to azithromycin could alter the fetal microbiome, Dr. Tita said he shares that concern but the answer is still unknown.
“We have collected additional information and specimens and we will be looking at these to try and answer this. We also hope to get funding to do a long-term evaluation of these kids. I will say that we collected adverse event data on them for 3 months and we did not see anything concerning, but I agree more needs to be done,” he said. “Having said that, azithromycin is something we already use quite a lot in obstetrics, and overall it has been shown to be safe for the newborn.”
The study was sponsored by the National Institute of Child Health and Human Development. Dr. Tita reported having no financial disclosures.
AT THE PREGNANCY MEETING
Key clinical point: Prophylactic azithromycin added to standard antibiotics decreased maternal infections after cesarean.
Major finding: The number needed to treat to prevent one postsurgical infection was 17.
Data source: The randomized, placebo-controlled trial comprised 2,013 women.
Disclosures: The study was sponsored by the National Institute of Child Health and Human Development. Dr. Tita reported having no financial disclosures.
New postop pain guideline: Multiple approaches to target different pain mechanisms
Clinicians should use multiple approaches to target different pain mechanisms when treating postsurgical pain, according to a Clinical Practice Guideline for this aspect of patient care published by the American Pain Society in the February issue of the Journal of Pain.
Postoperative pain management reportedly is inadequate for more than half of the adults and children who undergo surgery each year. In this setting, inadequate pain relief can contribute to impaired recovery, decreased physical function, postoperative complications, and poor quality of life, and it may even set the stage for the development of chronic pain, said Dr. Roger Chou, lead author of the guideline and professor of medicine and of medical informatics and clinical epidemiology, Oregon Health and Science University, Portland, and his associates.
The guideline includes 32 evidence-based recommendations for all clinicians who treat postoperative pain. It was compiled by a 23-member expert panel based on their analysis of 858 primary studies and 107 systematic reviews of the literature. Despite the panel’s efforts to obtain top-level evidence, of 32 recommendations, the panel rated only 4 as supported by high-quality evidence, and 11 recommendations were on the basis of low-quality evidence. The panel members had expertise in anesthesia, pain medicine, surgery, obstetrics and gynecology, primary care, pediatrics, hospital medicine, nursing, physical therapy, and psychology, said Dr. Chou, who is also director of the Pacific Northwest Evidence-Based Practice Center, Portland, and his associates.
The first strong recommendation, based on high-quality evidence, is to use a variety of medications and techniques that act on both the central and peripheral nervous systems and have been associated with both superior pain relief and decreased opioid consumption, compared with single agents or methods. For example, continuous nonopioid analgesia such as acetaminophen or NSAIDs can be combined with opioids that act on different receptors and with nonpharmacologic therapies. The guideline addresses several specific situations, and summarizes in a table the multimodal options for common surgeries such as laparotomy, total hip or knee replacement, coronary artery bypass graft, and cesarean section.
The guideline also strongly recommends that management of postsurgical pain should begin preoperatively, with assessment of the patient’s medical and psychiatric comorbidities; concomitant medications; and history of any chronic pain, substance abuse, and previous postoperative treatments and responses. Clinicians should use a validated pain assessment tool to track patients’ responses to postsurgical pain treatment and adjust treatment plans accordingly.
The guideline suggests that clinicians consider nonpharmacologic techniques including transcutaneous electrical nerve stimulation and cognitive-behavioral modalities such as guided imagery, relaxation methods, hypnosis, and intraoperative suggestion. At the very least, these are noninvasive and don’t appear to be associated with any harm. However, the guideline cautions that the evidence is insufficient to support cognitive-behavioral modalities in children. It also cannot recommend for or against several alternative treatments for which there is not yet sufficient evidence of efficacy, including acupuncture, massage, and cold therapy, Dr. Chou and his associates said (J Pain. 2016;17:131-57).
For adults who have no contraindications, a preoperative dose of celecoxib is strongly recommended because it improves postoperative pain and also reduces the need for opioids. One contraindication to celecoxib is CABG surgery, because of its attendant risk of adverse cardiovascular events. Preoperative doses of gabapentin or pregabalin also are strongly recommended as part of multimodal postsurgical analgesia, particularly for operations associated with substantial pain.
The guideline also strongly recommends epidural or spinal analgesia for major thoracic or abdominal procedures, especially for patients at risk for cardiac complications, pulmonary complications, or prolonged ileus. Compared with systemic analgesia, these forms appear to decrease the risk of death, venous thromboembolism, myocardial infarction, pneumonia, and respiratory depression. However, patients who receive neuraxial analgesia should still be carefully monitored, as they may develop respiratory depression, hypotension, or motor weakness, or the intervention might mask symptoms of compartment syndrome.
According to the guideline, all facilities that offer surgery should also provide clinicians with access to a pain specialist. The specialist should be available to consult for patients with inadequately controlled postoperative pain and to assist with diagnosis, interventions, or management of comorbid conditions. They may be especially useful for advising clinicians regarding patients who have opioid tolerance, especially if there is a history of substance abuse or addiction. Pain treatment should not be withheld from such patients “because of fears of worsening addiction or precipitation of relapse. In addition to the ethical requirement to address postoperative pain, poorly treated pain can be a trigger for relapse,” the guideline states.
The guideline also addresses the transition to outpatient care and identifies some research gaps. “Research is urgently needed on optimal methods for managing patients who receive opioids before surgery, effectiveness of opioid-sparing multimodal regimens, optimal methods of pain assessment and monitoring, and a number of areas related to management of perioperative pain in infants and children,” the panel concluded.
Funding for this guideline was provided by the American Pain Society. Dr. Chou’s and his associates’ financial disclosures are available at www.jpain.org.
Clinicians should use multiple approaches to target different pain mechanisms when treating postsurgical pain, according to a Clinical Practice Guideline for this aspect of patient care published by the American Pain Society in the February issue of the Journal of Pain.
Postoperative pain management reportedly is inadequate for more than half of the adults and children who undergo surgery each year. In this setting, inadequate pain relief can contribute to impaired recovery, decreased physical function, postoperative complications, and poor quality of life, and it may even set the stage for the development of chronic pain, said Dr. Roger Chou, lead author of the guideline and professor of medicine and of medical informatics and clinical epidemiology, Oregon Health and Science University, Portland, and his associates.
The guideline includes 32 evidence-based recommendations for all clinicians who treat postoperative pain. It was compiled by a 23-member expert panel based on their analysis of 858 primary studies and 107 systematic reviews of the literature. Despite the panel’s efforts to obtain top-level evidence, of 32 recommendations, the panel rated only 4 as supported by high-quality evidence, and 11 recommendations were on the basis of low-quality evidence. The panel members had expertise in anesthesia, pain medicine, surgery, obstetrics and gynecology, primary care, pediatrics, hospital medicine, nursing, physical therapy, and psychology, said Dr. Chou, who is also director of the Pacific Northwest Evidence-Based Practice Center, Portland, and his associates.
The first strong recommendation, based on high-quality evidence, is to use a variety of medications and techniques that act on both the central and peripheral nervous systems and have been associated with both superior pain relief and decreased opioid consumption, compared with single agents or methods. For example, continuous nonopioid analgesia such as acetaminophen or NSAIDs can be combined with opioids that act on different receptors and with nonpharmacologic therapies. The guideline addresses several specific situations, and summarizes in a table the multimodal options for common surgeries such as laparotomy, total hip or knee replacement, coronary artery bypass graft, and cesarean section.
The guideline also strongly recommends that management of postsurgical pain should begin preoperatively, with assessment of the patient’s medical and psychiatric comorbidities; concomitant medications; and history of any chronic pain, substance abuse, and previous postoperative treatments and responses. Clinicians should use a validated pain assessment tool to track patients’ responses to postsurgical pain treatment and adjust treatment plans accordingly.
The guideline suggests that clinicians consider nonpharmacologic techniques including transcutaneous electrical nerve stimulation and cognitive-behavioral modalities such as guided imagery, relaxation methods, hypnosis, and intraoperative suggestion. At the very least, these are noninvasive and don’t appear to be associated with any harm. However, the guideline cautions that the evidence is insufficient to support cognitive-behavioral modalities in children. It also cannot recommend for or against several alternative treatments for which there is not yet sufficient evidence of efficacy, including acupuncture, massage, and cold therapy, Dr. Chou and his associates said (J Pain. 2016;17:131-57).
For adults who have no contraindications, a preoperative dose of celecoxib is strongly recommended because it improves postoperative pain and also reduces the need for opioids. One contraindication to celecoxib is CABG surgery, because of its attendant risk of adverse cardiovascular events. Preoperative doses of gabapentin or pregabalin also are strongly recommended as part of multimodal postsurgical analgesia, particularly for operations associated with substantial pain.
The guideline also strongly recommends epidural or spinal analgesia for major thoracic or abdominal procedures, especially for patients at risk for cardiac complications, pulmonary complications, or prolonged ileus. Compared with systemic analgesia, these forms appear to decrease the risk of death, venous thromboembolism, myocardial infarction, pneumonia, and respiratory depression. However, patients who receive neuraxial analgesia should still be carefully monitored, as they may develop respiratory depression, hypotension, or motor weakness, or the intervention might mask symptoms of compartment syndrome.
According to the guideline, all facilities that offer surgery should also provide clinicians with access to a pain specialist. The specialist should be available to consult for patients with inadequately controlled postoperative pain and to assist with diagnosis, interventions, or management of comorbid conditions. They may be especially useful for advising clinicians regarding patients who have opioid tolerance, especially if there is a history of substance abuse or addiction. Pain treatment should not be withheld from such patients “because of fears of worsening addiction or precipitation of relapse. In addition to the ethical requirement to address postoperative pain, poorly treated pain can be a trigger for relapse,” the guideline states.
The guideline also addresses the transition to outpatient care and identifies some research gaps. “Research is urgently needed on optimal methods for managing patients who receive opioids before surgery, effectiveness of opioid-sparing multimodal regimens, optimal methods of pain assessment and monitoring, and a number of areas related to management of perioperative pain in infants and children,” the panel concluded.
Funding for this guideline was provided by the American Pain Society. Dr. Chou’s and his associates’ financial disclosures are available at www.jpain.org.
Clinicians should use multiple approaches to target different pain mechanisms when treating postsurgical pain, according to a Clinical Practice Guideline for this aspect of patient care published by the American Pain Society in the February issue of the Journal of Pain.
Postoperative pain management reportedly is inadequate for more than half of the adults and children who undergo surgery each year. In this setting, inadequate pain relief can contribute to impaired recovery, decreased physical function, postoperative complications, and poor quality of life, and it may even set the stage for the development of chronic pain, said Dr. Roger Chou, lead author of the guideline and professor of medicine and of medical informatics and clinical epidemiology, Oregon Health and Science University, Portland, and his associates.
The guideline includes 32 evidence-based recommendations for all clinicians who treat postoperative pain. It was compiled by a 23-member expert panel based on their analysis of 858 primary studies and 107 systematic reviews of the literature. Despite the panel’s efforts to obtain top-level evidence, of 32 recommendations, the panel rated only 4 as supported by high-quality evidence, and 11 recommendations were on the basis of low-quality evidence. The panel members had expertise in anesthesia, pain medicine, surgery, obstetrics and gynecology, primary care, pediatrics, hospital medicine, nursing, physical therapy, and psychology, said Dr. Chou, who is also director of the Pacific Northwest Evidence-Based Practice Center, Portland, and his associates.
The first strong recommendation, based on high-quality evidence, is to use a variety of medications and techniques that act on both the central and peripheral nervous systems and have been associated with both superior pain relief and decreased opioid consumption, compared with single agents or methods. For example, continuous nonopioid analgesia such as acetaminophen or NSAIDs can be combined with opioids that act on different receptors and with nonpharmacologic therapies. The guideline addresses several specific situations, and summarizes in a table the multimodal options for common surgeries such as laparotomy, total hip or knee replacement, coronary artery bypass graft, and cesarean section.
The guideline also strongly recommends that management of postsurgical pain should begin preoperatively, with assessment of the patient’s medical and psychiatric comorbidities; concomitant medications; and history of any chronic pain, substance abuse, and previous postoperative treatments and responses. Clinicians should use a validated pain assessment tool to track patients’ responses to postsurgical pain treatment and adjust treatment plans accordingly.
The guideline suggests that clinicians consider nonpharmacologic techniques including transcutaneous electrical nerve stimulation and cognitive-behavioral modalities such as guided imagery, relaxation methods, hypnosis, and intraoperative suggestion. At the very least, these are noninvasive and don’t appear to be associated with any harm. However, the guideline cautions that the evidence is insufficient to support cognitive-behavioral modalities in children. It also cannot recommend for or against several alternative treatments for which there is not yet sufficient evidence of efficacy, including acupuncture, massage, and cold therapy, Dr. Chou and his associates said (J Pain. 2016;17:131-57).
For adults who have no contraindications, a preoperative dose of celecoxib is strongly recommended because it improves postoperative pain and also reduces the need for opioids. One contraindication to celecoxib is CABG surgery, because of its attendant risk of adverse cardiovascular events. Preoperative doses of gabapentin or pregabalin also are strongly recommended as part of multimodal postsurgical analgesia, particularly for operations associated with substantial pain.
The guideline also strongly recommends epidural or spinal analgesia for major thoracic or abdominal procedures, especially for patients at risk for cardiac complications, pulmonary complications, or prolonged ileus. Compared with systemic analgesia, these forms appear to decrease the risk of death, venous thromboembolism, myocardial infarction, pneumonia, and respiratory depression. However, patients who receive neuraxial analgesia should still be carefully monitored, as they may develop respiratory depression, hypotension, or motor weakness, or the intervention might mask symptoms of compartment syndrome.
According to the guideline, all facilities that offer surgery should also provide clinicians with access to a pain specialist. The specialist should be available to consult for patients with inadequately controlled postoperative pain and to assist with diagnosis, interventions, or management of comorbid conditions. They may be especially useful for advising clinicians regarding patients who have opioid tolerance, especially if there is a history of substance abuse or addiction. Pain treatment should not be withheld from such patients “because of fears of worsening addiction or precipitation of relapse. In addition to the ethical requirement to address postoperative pain, poorly treated pain can be a trigger for relapse,” the guideline states.
The guideline also addresses the transition to outpatient care and identifies some research gaps. “Research is urgently needed on optimal methods for managing patients who receive opioids before surgery, effectiveness of opioid-sparing multimodal regimens, optimal methods of pain assessment and monitoring, and a number of areas related to management of perioperative pain in infants and children,” the panel concluded.
Funding for this guideline was provided by the American Pain Society. Dr. Chou’s and his associates’ financial disclosures are available at www.jpain.org.
FROM THE JOURNAL OF PAIN
Can ‘big data’ predict postop complications?
JACKSONVILLE, FLA. The potential of “big data” to predict surgical complications has long been expected and that potential may now in the process of becoming a reality.
As health care moves to a value-based system that penalizes surgeons and hospitals for readmissions, the inability to predict postop complications remains a problem, but investigators at University of Wisconsin have found a way to use “big data” to create a model that may help surgeons identify at-risk individuals before complications occur.
Shara Feld, Ph.D., a medical student at Wisconsin, reported on the development of a Markov chain model that sequences random variables to calculate varying states over time. “A Markov model represents the patient progression through a series of health states,” Dr. Feld said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress
“A Markov chain model combining information about prior complications and the time to occurrence after surgery can inform our likelihood of specific future complications,” she said. “Understanding these relationships among complications can improve our ability to select targeted interventions, to avoid cascades of multiple complications, counsel patients and family on prognosis, assist with care decisions, and develop quality improvement measures.”
The model draws on 3 million operations in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2013. Of those, 400,000 cases involved one complication and 132,000 two or more complications, Dr. Feld said. From that, the investigators identified 21 different complications, including superficial, deep and organ surgical site infections, cardiac arrest, and pneumonia. The study accounted for complications within 30 days of the operation.
Dr. Feld pointed to one of the challenges using the existing literature on surgical risk assessment: “We know that patients can have one complication that can snowball into multiple complications, and as this snowball of complications develops, the postoperative risk in patient prognosis can change from what it was based on preoperative risk factors,” she said.
The model was best at predicting death, coma longer than a day, cardiac arrest, septic shock, renal failure, pneumonia, unplanned reintubation, ventilator use of more than 2 days, and bleeding transfusion, Dr. Feld said.
The study also found that complications most likely to cascade to a higher level were cardiac arrest, renal insufficiency or failure, stroke, intubation, septic shock, and coma, Dr. Feld said. For example, a patient who has a coma has an odds ratio greater than 1.5 of dying within 30 days of the operation while the odds ratio for death following a diagnosis of superficial surgical site infection is less than 0.5, the study found.
Evaluating population-based complication risks after surgery was difficult before the large ACS NSQIP database became available to researchers, Dr. Feld said. The model reveals the impact of specific complications, complication timing, and how combinations of multiple postoperative complications change the risk for the development of future complications..
This model has not to date looked at what type of procedure led to the complications but this line of research may be developed in the future, Dr. Feld said.
The authors had no financial relationships to disclose.
JACKSONVILLE, FLA. The potential of “big data” to predict surgical complications has long been expected and that potential may now in the process of becoming a reality.
As health care moves to a value-based system that penalizes surgeons and hospitals for readmissions, the inability to predict postop complications remains a problem, but investigators at University of Wisconsin have found a way to use “big data” to create a model that may help surgeons identify at-risk individuals before complications occur.
Shara Feld, Ph.D., a medical student at Wisconsin, reported on the development of a Markov chain model that sequences random variables to calculate varying states over time. “A Markov model represents the patient progression through a series of health states,” Dr. Feld said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress
“A Markov chain model combining information about prior complications and the time to occurrence after surgery can inform our likelihood of specific future complications,” she said. “Understanding these relationships among complications can improve our ability to select targeted interventions, to avoid cascades of multiple complications, counsel patients and family on prognosis, assist with care decisions, and develop quality improvement measures.”
The model draws on 3 million operations in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2013. Of those, 400,000 cases involved one complication and 132,000 two or more complications, Dr. Feld said. From that, the investigators identified 21 different complications, including superficial, deep and organ surgical site infections, cardiac arrest, and pneumonia. The study accounted for complications within 30 days of the operation.
Dr. Feld pointed to one of the challenges using the existing literature on surgical risk assessment: “We know that patients can have one complication that can snowball into multiple complications, and as this snowball of complications develops, the postoperative risk in patient prognosis can change from what it was based on preoperative risk factors,” she said.
The model was best at predicting death, coma longer than a day, cardiac arrest, septic shock, renal failure, pneumonia, unplanned reintubation, ventilator use of more than 2 days, and bleeding transfusion, Dr. Feld said.
The study also found that complications most likely to cascade to a higher level were cardiac arrest, renal insufficiency or failure, stroke, intubation, septic shock, and coma, Dr. Feld said. For example, a patient who has a coma has an odds ratio greater than 1.5 of dying within 30 days of the operation while the odds ratio for death following a diagnosis of superficial surgical site infection is less than 0.5, the study found.
Evaluating population-based complication risks after surgery was difficult before the large ACS NSQIP database became available to researchers, Dr. Feld said. The model reveals the impact of specific complications, complication timing, and how combinations of multiple postoperative complications change the risk for the development of future complications..
This model has not to date looked at what type of procedure led to the complications but this line of research may be developed in the future, Dr. Feld said.
The authors had no financial relationships to disclose.
JACKSONVILLE, FLA. The potential of “big data” to predict surgical complications has long been expected and that potential may now in the process of becoming a reality.
As health care moves to a value-based system that penalizes surgeons and hospitals for readmissions, the inability to predict postop complications remains a problem, but investigators at University of Wisconsin have found a way to use “big data” to create a model that may help surgeons identify at-risk individuals before complications occur.
Shara Feld, Ph.D., a medical student at Wisconsin, reported on the development of a Markov chain model that sequences random variables to calculate varying states over time. “A Markov model represents the patient progression through a series of health states,” Dr. Feld said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress
“A Markov chain model combining information about prior complications and the time to occurrence after surgery can inform our likelihood of specific future complications,” she said. “Understanding these relationships among complications can improve our ability to select targeted interventions, to avoid cascades of multiple complications, counsel patients and family on prognosis, assist with care decisions, and develop quality improvement measures.”
The model draws on 3 million operations in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2013. Of those, 400,000 cases involved one complication and 132,000 two or more complications, Dr. Feld said. From that, the investigators identified 21 different complications, including superficial, deep and organ surgical site infections, cardiac arrest, and pneumonia. The study accounted for complications within 30 days of the operation.
Dr. Feld pointed to one of the challenges using the existing literature on surgical risk assessment: “We know that patients can have one complication that can snowball into multiple complications, and as this snowball of complications develops, the postoperative risk in patient prognosis can change from what it was based on preoperative risk factors,” she said.
The model was best at predicting death, coma longer than a day, cardiac arrest, septic shock, renal failure, pneumonia, unplanned reintubation, ventilator use of more than 2 days, and bleeding transfusion, Dr. Feld said.
The study also found that complications most likely to cascade to a higher level were cardiac arrest, renal insufficiency or failure, stroke, intubation, septic shock, and coma, Dr. Feld said. For example, a patient who has a coma has an odds ratio greater than 1.5 of dying within 30 days of the operation while the odds ratio for death following a diagnosis of superficial surgical site infection is less than 0.5, the study found.
Evaluating population-based complication risks after surgery was difficult before the large ACS NSQIP database became available to researchers, Dr. Feld said. The model reveals the impact of specific complications, complication timing, and how combinations of multiple postoperative complications change the risk for the development of future complications..
This model has not to date looked at what type of procedure led to the complications but this line of research may be developed in the future, Dr. Feld said.
The authors had no financial relationships to disclose.
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point: A Markov chain model using data from the American College of Surgeons National Surgical Quality Improvement Program may provide a tool for predicting complications after surgery.
Major finding: The model was best at predicting death, coma longer than a day, cardiac arrest, septic shock, renal failure, pneumonia, unplanned reintubation, ventilator use of more than 2 days, and bleeding.
Data source: The model draws on 3 million operations in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2013.
Disclosures: The study authors reported having no financial disclosures.
Aortic aneurysms pose unique challenges in transplant recipients
CHICAGO – Surgeons can expect to see more abdominal organ transplant recipients presenting with aortic aneurysms, as transplant survival rates increase along with the age of organ donors and recipients.
“The consensus is that abdominal aortic aneurysms (AAAs) have a more aggressive course post-transplant and within that context, probably need to be managed more aggressively,” Dr. Michael J. Englesbe of the University of Michigan, Ann Arbor said at the annual Northwestern Vascular Symposium.
Some 270,000 Americans are living with a functioning liver or kidney graft, and their average age has risen from 47 years to 57 years over the last decade.
Though the data isn’t great, it’s hypothesized that the immunosuppression prerequisite for successful organ transplantation promotes the progression of atherosclerosis and aneurysm growth in transplant patients, he said.
New-onset diabetes, hyperlipidemia, and hypertension are all common post-transplant due to immunosuppression therapy. Aortic aneurysms are also reported to rupture at smaller sizes in transplant recipients.
Intriguingly, the opposite effect has been observed in experimental animal models, where immunosuppression with calcineurin inhibitors and mammalian target of rapamycin (mTOR) inhibitors has been shown to stabilize atherosclerotic lesions and inhibit aneurysm expansion.
The reason for this disparity is unclear, but immunosuppressants likely augment other cardiovascular comorbidities such as hypertension and atherosclerosis and this may trump their anti-inflammatory effects and lead to worse aneurysm disease and faster expansion in humans, Dr. Englesbe speculated in an interview.
As for when aneurysms should be fixed, kidney transplant candidates should undergo AAA repair prior to transplantation since the risk of renal complications after aneurysm repair puts the allograft at risk, Dr. Englesbe advised. Either an open or endovascular approach can be used.
In liver transplant candidates, elective AAA repair should be avoided if possible and is contraindicated if any signs of hepatic decompensation are present such as muscle wasting, ascites, platelet count less than 50 x 109/L, or encephalopathy. For well-compensated cirrhotic patients, endovascular repair is best.
One of the most important considerations for any solid-organ transplant patient undergoing aneurysm repair is perioperative management of immunosuppression, Dr. Englesbe stressed.
Transplant patients are maintained on oral calcineurin inhibitors such as cyclosporine and tacrolimus (Prograf) throughout the perioperative period to prevent organ rejection, but these drugs have nephrotoxic effects. About 10% of recipients, typically the sicker patients, will be switched to mTOR inhibitors such as everolimus (Afinitor) and sirolumus (Rapamune) as a kidney-sparing alternative.
“Part of the mechanism of these [mTOR] drugs is that they really affect fibroblast functioning, so patients that are on these medications, their wound will fall apart and they will invariably get a hernia,” Dr. Englesbe said. “You have to stop them upwards of about 6 weeks before surgical intervention, and I think this is also true for many endografts.”
He highlighted a case in which an mTOR inhibitor was started three months after liver transplant due to renal dysfunction in a patient who was fully healed, but within three weeks, “her wound fell apart, completely fell apart.” She developed several seromas underneath her incision, one of which became infected and took months to close.
“The transplant professionals – your nephrologists, your cardiologists – aren’t going to know this fact, but as a transplant surgeon it’s usually the first question we’re going to ask with respect to any post-transplant patient we’re going to operate on, so it’s something to keep in mind,” Dr. Englesbe said.
Another take-home message was the importance of maintaining kidney function in kidney recipients presenting with aortic aneurysm, as mortality in these patients is about 10-fold higher once the kidney fails, he said. A recent study reported that AAAs are significantly more common in kidney than liver transplant recipients (29.6% vs. 11.4%; P = .02), despite a similar prevalence for any aneurysm (4%) in both groups (J Vasc Surg. 2014 Mar;59;594-8).
When kidney recipients present, preoperative imaging of the aorta from the aneurysm to the kidney allograft is mandatory, he said. Endovascular repair is preferred, whenever possible.
The renal graft is typically sewn to the external iliac artery 3 cm to 10 cm from the bifurcation of the external and internal iliac arteries. Because of this, repair is challenging when aneurysmal disease involves the iliac artery, Dr. Englesbe observed. Aneurysmal dilation is less common in the external iliac, but stenting an iliac aneurysm can still compromise inflow to the transplanted kidney.
Several surgical techniques including axillofemoral bypass, aortofemoral shunt, or extracorporeal circuit have been reported to preserve renal function during open AAA repair in renal transplant recipients. These techniques are not without their own risk of complications and should be avoided in patients with low creatinine, but are appropriate in patients with marginal or impaired renal function, according to Dr. Englesbe, who reported having no relevant disclosures.
CHICAGO – Surgeons can expect to see more abdominal organ transplant recipients presenting with aortic aneurysms, as transplant survival rates increase along with the age of organ donors and recipients.
“The consensus is that abdominal aortic aneurysms (AAAs) have a more aggressive course post-transplant and within that context, probably need to be managed more aggressively,” Dr. Michael J. Englesbe of the University of Michigan, Ann Arbor said at the annual Northwestern Vascular Symposium.
Some 270,000 Americans are living with a functioning liver or kidney graft, and their average age has risen from 47 years to 57 years over the last decade.
Though the data isn’t great, it’s hypothesized that the immunosuppression prerequisite for successful organ transplantation promotes the progression of atherosclerosis and aneurysm growth in transplant patients, he said.
New-onset diabetes, hyperlipidemia, and hypertension are all common post-transplant due to immunosuppression therapy. Aortic aneurysms are also reported to rupture at smaller sizes in transplant recipients.
Intriguingly, the opposite effect has been observed in experimental animal models, where immunosuppression with calcineurin inhibitors and mammalian target of rapamycin (mTOR) inhibitors has been shown to stabilize atherosclerotic lesions and inhibit aneurysm expansion.
The reason for this disparity is unclear, but immunosuppressants likely augment other cardiovascular comorbidities such as hypertension and atherosclerosis and this may trump their anti-inflammatory effects and lead to worse aneurysm disease and faster expansion in humans, Dr. Englesbe speculated in an interview.
As for when aneurysms should be fixed, kidney transplant candidates should undergo AAA repair prior to transplantation since the risk of renal complications after aneurysm repair puts the allograft at risk, Dr. Englesbe advised. Either an open or endovascular approach can be used.
In liver transplant candidates, elective AAA repair should be avoided if possible and is contraindicated if any signs of hepatic decompensation are present such as muscle wasting, ascites, platelet count less than 50 x 109/L, or encephalopathy. For well-compensated cirrhotic patients, endovascular repair is best.
One of the most important considerations for any solid-organ transplant patient undergoing aneurysm repair is perioperative management of immunosuppression, Dr. Englesbe stressed.
Transplant patients are maintained on oral calcineurin inhibitors such as cyclosporine and tacrolimus (Prograf) throughout the perioperative period to prevent organ rejection, but these drugs have nephrotoxic effects. About 10% of recipients, typically the sicker patients, will be switched to mTOR inhibitors such as everolimus (Afinitor) and sirolumus (Rapamune) as a kidney-sparing alternative.
“Part of the mechanism of these [mTOR] drugs is that they really affect fibroblast functioning, so patients that are on these medications, their wound will fall apart and they will invariably get a hernia,” Dr. Englesbe said. “You have to stop them upwards of about 6 weeks before surgical intervention, and I think this is also true for many endografts.”
He highlighted a case in which an mTOR inhibitor was started three months after liver transplant due to renal dysfunction in a patient who was fully healed, but within three weeks, “her wound fell apart, completely fell apart.” She developed several seromas underneath her incision, one of which became infected and took months to close.
“The transplant professionals – your nephrologists, your cardiologists – aren’t going to know this fact, but as a transplant surgeon it’s usually the first question we’re going to ask with respect to any post-transplant patient we’re going to operate on, so it’s something to keep in mind,” Dr. Englesbe said.
Another take-home message was the importance of maintaining kidney function in kidney recipients presenting with aortic aneurysm, as mortality in these patients is about 10-fold higher once the kidney fails, he said. A recent study reported that AAAs are significantly more common in kidney than liver transplant recipients (29.6% vs. 11.4%; P = .02), despite a similar prevalence for any aneurysm (4%) in both groups (J Vasc Surg. 2014 Mar;59;594-8).
When kidney recipients present, preoperative imaging of the aorta from the aneurysm to the kidney allograft is mandatory, he said. Endovascular repair is preferred, whenever possible.
The renal graft is typically sewn to the external iliac artery 3 cm to 10 cm from the bifurcation of the external and internal iliac arteries. Because of this, repair is challenging when aneurysmal disease involves the iliac artery, Dr. Englesbe observed. Aneurysmal dilation is less common in the external iliac, but stenting an iliac aneurysm can still compromise inflow to the transplanted kidney.
Several surgical techniques including axillofemoral bypass, aortofemoral shunt, or extracorporeal circuit have been reported to preserve renal function during open AAA repair in renal transplant recipients. These techniques are not without their own risk of complications and should be avoided in patients with low creatinine, but are appropriate in patients with marginal or impaired renal function, according to Dr. Englesbe, who reported having no relevant disclosures.
CHICAGO – Surgeons can expect to see more abdominal organ transplant recipients presenting with aortic aneurysms, as transplant survival rates increase along with the age of organ donors and recipients.
“The consensus is that abdominal aortic aneurysms (AAAs) have a more aggressive course post-transplant and within that context, probably need to be managed more aggressively,” Dr. Michael J. Englesbe of the University of Michigan, Ann Arbor said at the annual Northwestern Vascular Symposium.
Some 270,000 Americans are living with a functioning liver or kidney graft, and their average age has risen from 47 years to 57 years over the last decade.
Though the data isn’t great, it’s hypothesized that the immunosuppression prerequisite for successful organ transplantation promotes the progression of atherosclerosis and aneurysm growth in transplant patients, he said.
New-onset diabetes, hyperlipidemia, and hypertension are all common post-transplant due to immunosuppression therapy. Aortic aneurysms are also reported to rupture at smaller sizes in transplant recipients.
Intriguingly, the opposite effect has been observed in experimental animal models, where immunosuppression with calcineurin inhibitors and mammalian target of rapamycin (mTOR) inhibitors has been shown to stabilize atherosclerotic lesions and inhibit aneurysm expansion.
The reason for this disparity is unclear, but immunosuppressants likely augment other cardiovascular comorbidities such as hypertension and atherosclerosis and this may trump their anti-inflammatory effects and lead to worse aneurysm disease and faster expansion in humans, Dr. Englesbe speculated in an interview.
As for when aneurysms should be fixed, kidney transplant candidates should undergo AAA repair prior to transplantation since the risk of renal complications after aneurysm repair puts the allograft at risk, Dr. Englesbe advised. Either an open or endovascular approach can be used.
In liver transplant candidates, elective AAA repair should be avoided if possible and is contraindicated if any signs of hepatic decompensation are present such as muscle wasting, ascites, platelet count less than 50 x 109/L, or encephalopathy. For well-compensated cirrhotic patients, endovascular repair is best.
One of the most important considerations for any solid-organ transplant patient undergoing aneurysm repair is perioperative management of immunosuppression, Dr. Englesbe stressed.
Transplant patients are maintained on oral calcineurin inhibitors such as cyclosporine and tacrolimus (Prograf) throughout the perioperative period to prevent organ rejection, but these drugs have nephrotoxic effects. About 10% of recipients, typically the sicker patients, will be switched to mTOR inhibitors such as everolimus (Afinitor) and sirolumus (Rapamune) as a kidney-sparing alternative.
“Part of the mechanism of these [mTOR] drugs is that they really affect fibroblast functioning, so patients that are on these medications, their wound will fall apart and they will invariably get a hernia,” Dr. Englesbe said. “You have to stop them upwards of about 6 weeks before surgical intervention, and I think this is also true for many endografts.”
He highlighted a case in which an mTOR inhibitor was started three months after liver transplant due to renal dysfunction in a patient who was fully healed, but within three weeks, “her wound fell apart, completely fell apart.” She developed several seromas underneath her incision, one of which became infected and took months to close.
“The transplant professionals – your nephrologists, your cardiologists – aren’t going to know this fact, but as a transplant surgeon it’s usually the first question we’re going to ask with respect to any post-transplant patient we’re going to operate on, so it’s something to keep in mind,” Dr. Englesbe said.
Another take-home message was the importance of maintaining kidney function in kidney recipients presenting with aortic aneurysm, as mortality in these patients is about 10-fold higher once the kidney fails, he said. A recent study reported that AAAs are significantly more common in kidney than liver transplant recipients (29.6% vs. 11.4%; P = .02), despite a similar prevalence for any aneurysm (4%) in both groups (J Vasc Surg. 2014 Mar;59;594-8).
When kidney recipients present, preoperative imaging of the aorta from the aneurysm to the kidney allograft is mandatory, he said. Endovascular repair is preferred, whenever possible.
The renal graft is typically sewn to the external iliac artery 3 cm to 10 cm from the bifurcation of the external and internal iliac arteries. Because of this, repair is challenging when aneurysmal disease involves the iliac artery, Dr. Englesbe observed. Aneurysmal dilation is less common in the external iliac, but stenting an iliac aneurysm can still compromise inflow to the transplanted kidney.
Several surgical techniques including axillofemoral bypass, aortofemoral shunt, or extracorporeal circuit have been reported to preserve renal function during open AAA repair in renal transplant recipients. These techniques are not without their own risk of complications and should be avoided in patients with low creatinine, but are appropriate in patients with marginal or impaired renal function, according to Dr. Englesbe, who reported having no relevant disclosures.
EXPERT ANALYSIS FROM THE NORTHWESTERN VASCULAR SYMPOSIUM
ERAS eliminated racial disparities in postop hospital stay
JACKSONVILLE, FLA. – An enhanced recovery protocol after colorectal surgery nearly eliminated differences in hospital stays between black and white patients, according to a study based on data from the University of Alabama at Birmingham.
Dr. Tyler S. Wahl, a resident at UAB reported on the institution’s experience with the Enhanced Recovery After Surgery (ERAS) pathway at the Association of Academic Surgery/Society of University Surgeons Academic Surgical Congress. “ERAS has been shown to reduce length of stay, cost, and perioperative complications without compromising readmission or mortality rates,” Dr. Wahl said. Dr. Daniel Chu was senior author.
Surgical literature has increasingly demonstrated disparities among black patients undergoing major surgery: longer lengths of stay, more readmissions, increased postoperative mortality and lower survival rates after colorectal cancer resections, Dr. Wahl said. The UAB investigators set out to determine whether the ERAS pathway would reduce disparities in length of stay among black and white patients when compared to the traditional pathway.
Before UAB started using ERAS for colorectal patients, the average length of stay for patients undergoing colorectal surgery was 6.7 days with significant differences between black and white patients: 8 days vs. 6.1 days, respectively. However, after implementation of the ERAS pathway in January 2015, average length of stay declined to 4.7 days overall. Black patients had dramatic reductions in length of stay, compared with white patients, with stays of 3.9 days vs. 5 days, respectively.
“Not only were patients leaving much earlier, but their length of stay was also shorter than predicted using the American College of Surgeons Risk Calculator,” Dr. Wahl said.
The UAB study was a retrospective, matched cohort analysis of 258 patients – 129 patients from pre-ERAS years were compared with 129 ERAS patients from January to October 2015.
Study subjects were similar in many patient- and procedure-specific factors; however, differences in operative approach, indication, ostomy formation, and operative time did not change the predicted length of stay among races, Dr. Wahl said.
Dr. Wahl said the racial makeup of the study differs from most ERAS literature in colorectal patients. “The overall percentage of the African American population was 30% within our study, as most ERAS literature has 10% or less,” he added.
“Further work needs to be pursued to find what’s driving these dramatic results among the black population,” he said.
Dr. Wahl and coauthors had no disclosures.
JACKSONVILLE, FLA. – An enhanced recovery protocol after colorectal surgery nearly eliminated differences in hospital stays between black and white patients, according to a study based on data from the University of Alabama at Birmingham.
Dr. Tyler S. Wahl, a resident at UAB reported on the institution’s experience with the Enhanced Recovery After Surgery (ERAS) pathway at the Association of Academic Surgery/Society of University Surgeons Academic Surgical Congress. “ERAS has been shown to reduce length of stay, cost, and perioperative complications without compromising readmission or mortality rates,” Dr. Wahl said. Dr. Daniel Chu was senior author.
Surgical literature has increasingly demonstrated disparities among black patients undergoing major surgery: longer lengths of stay, more readmissions, increased postoperative mortality and lower survival rates after colorectal cancer resections, Dr. Wahl said. The UAB investigators set out to determine whether the ERAS pathway would reduce disparities in length of stay among black and white patients when compared to the traditional pathway.
Before UAB started using ERAS for colorectal patients, the average length of stay for patients undergoing colorectal surgery was 6.7 days with significant differences between black and white patients: 8 days vs. 6.1 days, respectively. However, after implementation of the ERAS pathway in January 2015, average length of stay declined to 4.7 days overall. Black patients had dramatic reductions in length of stay, compared with white patients, with stays of 3.9 days vs. 5 days, respectively.
“Not only were patients leaving much earlier, but their length of stay was also shorter than predicted using the American College of Surgeons Risk Calculator,” Dr. Wahl said.
The UAB study was a retrospective, matched cohort analysis of 258 patients – 129 patients from pre-ERAS years were compared with 129 ERAS patients from January to October 2015.
Study subjects were similar in many patient- and procedure-specific factors; however, differences in operative approach, indication, ostomy formation, and operative time did not change the predicted length of stay among races, Dr. Wahl said.
Dr. Wahl said the racial makeup of the study differs from most ERAS literature in colorectal patients. “The overall percentage of the African American population was 30% within our study, as most ERAS literature has 10% or less,” he added.
“Further work needs to be pursued to find what’s driving these dramatic results among the black population,” he said.
Dr. Wahl and coauthors had no disclosures.
JACKSONVILLE, FLA. – An enhanced recovery protocol after colorectal surgery nearly eliminated differences in hospital stays between black and white patients, according to a study based on data from the University of Alabama at Birmingham.
Dr. Tyler S. Wahl, a resident at UAB reported on the institution’s experience with the Enhanced Recovery After Surgery (ERAS) pathway at the Association of Academic Surgery/Society of University Surgeons Academic Surgical Congress. “ERAS has been shown to reduce length of stay, cost, and perioperative complications without compromising readmission or mortality rates,” Dr. Wahl said. Dr. Daniel Chu was senior author.
Surgical literature has increasingly demonstrated disparities among black patients undergoing major surgery: longer lengths of stay, more readmissions, increased postoperative mortality and lower survival rates after colorectal cancer resections, Dr. Wahl said. The UAB investigators set out to determine whether the ERAS pathway would reduce disparities in length of stay among black and white patients when compared to the traditional pathway.
Before UAB started using ERAS for colorectal patients, the average length of stay for patients undergoing colorectal surgery was 6.7 days with significant differences between black and white patients: 8 days vs. 6.1 days, respectively. However, after implementation of the ERAS pathway in January 2015, average length of stay declined to 4.7 days overall. Black patients had dramatic reductions in length of stay, compared with white patients, with stays of 3.9 days vs. 5 days, respectively.
“Not only were patients leaving much earlier, but their length of stay was also shorter than predicted using the American College of Surgeons Risk Calculator,” Dr. Wahl said.
The UAB study was a retrospective, matched cohort analysis of 258 patients – 129 patients from pre-ERAS years were compared with 129 ERAS patients from January to October 2015.
Study subjects were similar in many patient- and procedure-specific factors; however, differences in operative approach, indication, ostomy formation, and operative time did not change the predicted length of stay among races, Dr. Wahl said.
Dr. Wahl said the racial makeup of the study differs from most ERAS literature in colorectal patients. “The overall percentage of the African American population was 30% within our study, as most ERAS literature has 10% or less,” he added.
“Further work needs to be pursued to find what’s driving these dramatic results among the black population,” he said.
Dr. Wahl and coauthors had no disclosures.
FROM THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Use of the ERAS pathway reduced hospital stays for all patients after colorectal surgery, with results most dramatic in black patients.
Major finding: Hospital stays declined from 6.7 days before ERAS to 4.7 days afterward, with stays for blacks declining from 8 days before ERAS to 3.9 days afterward.
Data source: Retrospective, matched cohort analysis of 258 patients – 129 patients from pre-ERAS years were compared to 129 ERAS patients from January to October 2015.
Disclosures: The study authors reported having no financial disclosures.
STS: Risk score predicts rehospitalization after heart surgery
PHOENIX – A simple, five-element formula can help identify the patients undergoing heart surgery who face the greatest risk for a hospital readmission within 30 days following discharge from their index hospitalization.
The surgeons who developed this formula hope to use it in an investigational program that will target intensified management resources in postsurgical patients who face the highest readmission risk, to cut rehospitalizations and better improve their clinical status and quality of life.
The analysis that produced this formula also documented that the worst offender for triggering rehospitalizations following heart surgery is fluid overload, the proximate readmission cause for 23% of postsurgical patients, Dr. Arman Kilic said at the annual meeting of the Society of Thoracic Surgeons. The next most common cause was infection, which led to 20% of readmissions, followed by arrhythmias, responsible for 8% of readmissions, said Dr. Kilic, a thoracic surgeon at the University of Pennsylvania in Philadelphia.
Because fluid overload, often in the form of pleural effusion, is such an important driver of rehospitalizations, a more targeted management program would include better titration of diuretic treatment to patients following heart surgery, thoracentesis, and closer monitoring of clinical features that flag fluid overload such as weight.
“The volume overload issue is where the money is. If we can reduce that, it could really impact readmissions,” Dr. Kilic said in an interview.
An investigational program to target rehospitalization risk in heart surgery patients is planned at Johns Hopkins Hospital in Baltimore, where Dr. Kilic worked when he performed this analysis. Surgeons at Johns Hopkins are now in the process of getting funding for this pilot program, said Dr. John V. Conte Jr., professor of surgery and director of mechanical circulatory support at Johns Hopkins and a collaborator with Dr. Kilic on developing the risk formula.
“We’ll tailor postoperative follow-up. We’ll get high-risk patients back to the clinic sooner, and we’ll send nurse practitioners to see them to make sure they’re taking their medications and are getting weighed daily,” Dr. Conte said in an interview. “When a patient has heart surgery, they typically retain about 5-10 pounds of fluid. Patients with good renal function give up that fluid easily, but others are difficult to diurese. Many patients go home before they have been fully diuresed, and we need to follow these patients and transition them better to out-of-hospital care.”
He noted that other situations also come up that unnecessarily drive patients back to the hospital when an alternative and less expensive intervention might be equally effective. For example, some patients return to the hospital out of concern for how their chest wound is healing. Instead of being rehospitalized, such patients could be reassured by having them send a nurse a photo of their wound or by coming to an outpatient clinic.
“We need to engage more often with recently discharged patients,” Dr. Conte said in an interview. “Discharging them doesn’t mean separating them from the health care system; it should mean interacting with patients in a different way” that produces better outcomes and patient satisfaction for less money. Developing improved ways to manage recent heart surgery patients following discharge becomes even more critical later this year when, in July, the Centers for Medicare & Medicaid Services adds 30-day readmissions following coronary artery bypass grafting (CABG) to its list of procedures that can generate a penalty to hospitals if they exceed U.S. norms for readmission rates.
The risk model developed by Dr. Kilic, Dr. Conte, and their associates used data collected from 5,360 heart surgery patients treated at Johns Hopkins during 2008-2013. Nearly half the patients underwent isolated CABG, and 20% had isolated valve surgery. Overall, 585 patients (11%) had a hospital readmission within 30 days of their index discharge. One limitation of the analysis was it used data only on readmissions back to Johns Hopkins Hospital.
The researchers used data from three-quarters of the database to derive the risk formula, and from the remaining 25% of the database to validate the formula. A multivariate analysis of demographic and clinical characteristics that significantly linked with an elevated risk for readmissions identified five factors that independently made a significant contribution to readmission risk. The researchers assigned each of these five factors points depending on its relative contribution to readmission risk in the adjusted model: Severe chronic lung disease received 6 points; placement of a ventricular assist device received 5 points, while other types of heart surgery that was not CABG or valve surgery received 4 points (isolated CABG, isolated valve, or combined CABG and valve surgery received 0 points); development of acute renal failure postoperatively but before index discharge received 4 points; an index length of stay beyond 7 days received 4 points; and African American race received 3 points. The maximum number of points a patient could receive was 22.
Patients with a score of 0 had a 6% rate of a 30-day readmission; those with a score of 22 had a 63% readmission rate. For simplicity, Dr. Kilic suggested dividing patients into three categories based on their readmission risk score: Low-risk patients with a score of 0 had a readmission risk of 6%, medium-risk patients with a score of 1-10 had a readmission risk of 12%, and high-risk patients with a score of 11 or more had a readmission risk of 31%. The researchers found a 96% correlation when comparing these predicted readmission risk rates based on the derivation-subgroup analysis with the actual readmission rates seen in the validation subgroup of their database. The targeted risk-management program planned by Dr. Conte would primarily focus on high-risk patients.
Dr. Kilic and Dr. Conte said they had no relevant financial disclosures.
On Twitter@mitchelzoler
Identifying the factors that determine whether a patient will need rehospitalization following discharge after heart surgery is a huge and unresolved problem. Risk models for the rate of hospital readmission following cardiothoracic surgery have historically performed poorly. Perhaps that’s because the models often fail to include factors with the strongest impact on readmissions. Most of the factors that appear to drive readmissions seem to be out of the direct control of hospital staffs, such as a lack of support for patients once they leave the hospital. Socioeconomic factors like this have usually not been included in risk models.
 |
Dr. David M. Shahian |
The C statistic (area under the receiver operating characteristic curve) for the model reported by Dr. Kilic was 0.66, very close to the 0.648 that my colleagues and I reported in 2014 for a risk model of 30-day hospital readmission following isolated coronary artery bypass grafting that used data from more than 162,000 Medicare patients who underwent surgery during 2008-2010 (Circulation. 2014 July 29;130[5]:399-409). This means that both models accounted for roughly two-thirds of the variability in readmission rates, which makes our model as well as Dr. Kilic’s model marginal in its ability to identify patients at greatest risk. Similar limitations exist for the other reported models for assessing the readmission risk following heart surgery.
One strength of the model reported by Dr. Kilic was its inclusion of patient factors that developed following the start of the index admission, such as postoperative acute renal failure.
Dr. David M. Shahian is a professor of surgery at Harvard Medical School and associate director of the Codman Center for Clinical Effectiveness in Surgery at the Massachusetts General Hospital, both in Boston. He made these comments during the discussion of Dr. Kilic’s report. Dr. Shahian had no relevant financial disclosures.
Identifying the factors that determine whether a patient will need rehospitalization following discharge after heart surgery is a huge and unresolved problem. Risk models for the rate of hospital readmission following cardiothoracic surgery have historically performed poorly. Perhaps that’s because the models often fail to include factors with the strongest impact on readmissions. Most of the factors that appear to drive readmissions seem to be out of the direct control of hospital staffs, such as a lack of support for patients once they leave the hospital. Socioeconomic factors like this have usually not been included in risk models.
|
Dr. David M. Shahian |
The C statistic (area under the receiver operating characteristic curve) for the model reported by Dr. Kilic was 0.66, very close to the 0.648 that my colleagues and I reported in 2014 for a risk model of 30-day hospital readmission following isolated coronary artery bypass grafting that used data from more than 162,000 Medicare patients who underwent surgery during 2008-2010 (Circulation. 2014 July 29;130[5]:399-409). This means that both models accounted for roughly two-thirds of the variability in readmission rates, which makes our model as well as Dr. Kilic’s model marginal in its ability to identify patients at greatest risk. Similar limitations exist for the other reported models for assessing the readmission risk following heart surgery.
One strength of the model reported by Dr. Kilic was its inclusion of patient factors that developed following the start of the index admission, such as postoperative acute renal failure.
Dr. David M. Shahian is a professor of surgery at Harvard Medical School and associate director of the Codman Center for Clinical Effectiveness in Surgery at the Massachusetts General Hospital, both in Boston. He made these comments during the discussion of Dr. Kilic’s report. Dr. Shahian had no relevant financial disclosures.
Identifying the factors that determine whether a patient will need rehospitalization following discharge after heart surgery is a huge and unresolved problem. Risk models for the rate of hospital readmission following cardiothoracic surgery have historically performed poorly. Perhaps that’s because the models often fail to include factors with the strongest impact on readmissions. Most of the factors that appear to drive readmissions seem to be out of the direct control of hospital staffs, such as a lack of support for patients once they leave the hospital. Socioeconomic factors like this have usually not been included in risk models.
|
Dr. David M. Shahian |
The C statistic (area under the receiver operating characteristic curve) for the model reported by Dr. Kilic was 0.66, very close to the 0.648 that my colleagues and I reported in 2014 for a risk model of 30-day hospital readmission following isolated coronary artery bypass grafting that used data from more than 162,000 Medicare patients who underwent surgery during 2008-2010 (Circulation. 2014 July 29;130[5]:399-409). This means that both models accounted for roughly two-thirds of the variability in readmission rates, which makes our model as well as Dr. Kilic’s model marginal in its ability to identify patients at greatest risk. Similar limitations exist for the other reported models for assessing the readmission risk following heart surgery.
One strength of the model reported by Dr. Kilic was its inclusion of patient factors that developed following the start of the index admission, such as postoperative acute renal failure.
Dr. David M. Shahian is a professor of surgery at Harvard Medical School and associate director of the Codman Center for Clinical Effectiveness in Surgery at the Massachusetts General Hospital, both in Boston. He made these comments during the discussion of Dr. Kilic’s report. Dr. Shahian had no relevant financial disclosures.
PHOENIX – A simple, five-element formula can help identify the patients undergoing heart surgery who face the greatest risk for a hospital readmission within 30 days following discharge from their index hospitalization.
The surgeons who developed this formula hope to use it in an investigational program that will target intensified management resources in postsurgical patients who face the highest readmission risk, to cut rehospitalizations and better improve their clinical status and quality of life.
The analysis that produced this formula also documented that the worst offender for triggering rehospitalizations following heart surgery is fluid overload, the proximate readmission cause for 23% of postsurgical patients, Dr. Arman Kilic said at the annual meeting of the Society of Thoracic Surgeons. The next most common cause was infection, which led to 20% of readmissions, followed by arrhythmias, responsible for 8% of readmissions, said Dr. Kilic, a thoracic surgeon at the University of Pennsylvania in Philadelphia.
Because fluid overload, often in the form of pleural effusion, is such an important driver of rehospitalizations, a more targeted management program would include better titration of diuretic treatment to patients following heart surgery, thoracentesis, and closer monitoring of clinical features that flag fluid overload such as weight.
“The volume overload issue is where the money is. If we can reduce that, it could really impact readmissions,” Dr. Kilic said in an interview.
An investigational program to target rehospitalization risk in heart surgery patients is planned at Johns Hopkins Hospital in Baltimore, where Dr. Kilic worked when he performed this analysis. Surgeons at Johns Hopkins are now in the process of getting funding for this pilot program, said Dr. John V. Conte Jr., professor of surgery and director of mechanical circulatory support at Johns Hopkins and a collaborator with Dr. Kilic on developing the risk formula.
“We’ll tailor postoperative follow-up. We’ll get high-risk patients back to the clinic sooner, and we’ll send nurse practitioners to see them to make sure they’re taking their medications and are getting weighed daily,” Dr. Conte said in an interview. “When a patient has heart surgery, they typically retain about 5-10 pounds of fluid. Patients with good renal function give up that fluid easily, but others are difficult to diurese. Many patients go home before they have been fully diuresed, and we need to follow these patients and transition them better to out-of-hospital care.”
He noted that other situations also come up that unnecessarily drive patients back to the hospital when an alternative and less expensive intervention might be equally effective. For example, some patients return to the hospital out of concern for how their chest wound is healing. Instead of being rehospitalized, such patients could be reassured by having them send a nurse a photo of their wound or by coming to an outpatient clinic.
“We need to engage more often with recently discharged patients,” Dr. Conte said in an interview. “Discharging them doesn’t mean separating them from the health care system; it should mean interacting with patients in a different way” that produces better outcomes and patient satisfaction for less money. Developing improved ways to manage recent heart surgery patients following discharge becomes even more critical later this year when, in July, the Centers for Medicare & Medicaid Services adds 30-day readmissions following coronary artery bypass grafting (CABG) to its list of procedures that can generate a penalty to hospitals if they exceed U.S. norms for readmission rates.
The risk model developed by Dr. Kilic, Dr. Conte, and their associates used data collected from 5,360 heart surgery patients treated at Johns Hopkins during 2008-2013. Nearly half the patients underwent isolated CABG, and 20% had isolated valve surgery. Overall, 585 patients (11%) had a hospital readmission within 30 days of their index discharge. One limitation of the analysis was it used data only on readmissions back to Johns Hopkins Hospital.
The researchers used data from three-quarters of the database to derive the risk formula, and from the remaining 25% of the database to validate the formula. A multivariate analysis of demographic and clinical characteristics that significantly linked with an elevated risk for readmissions identified five factors that independently made a significant contribution to readmission risk. The researchers assigned each of these five factors points depending on its relative contribution to readmission risk in the adjusted model: Severe chronic lung disease received 6 points; placement of a ventricular assist device received 5 points, while other types of heart surgery that was not CABG or valve surgery received 4 points (isolated CABG, isolated valve, or combined CABG and valve surgery received 0 points); development of acute renal failure postoperatively but before index discharge received 4 points; an index length of stay beyond 7 days received 4 points; and African American race received 3 points. The maximum number of points a patient could receive was 22.
Patients with a score of 0 had a 6% rate of a 30-day readmission; those with a score of 22 had a 63% readmission rate. For simplicity, Dr. Kilic suggested dividing patients into three categories based on their readmission risk score: Low-risk patients with a score of 0 had a readmission risk of 6%, medium-risk patients with a score of 1-10 had a readmission risk of 12%, and high-risk patients with a score of 11 or more had a readmission risk of 31%. The researchers found a 96% correlation when comparing these predicted readmission risk rates based on the derivation-subgroup analysis with the actual readmission rates seen in the validation subgroup of their database. The targeted risk-management program planned by Dr. Conte would primarily focus on high-risk patients.
Dr. Kilic and Dr. Conte said they had no relevant financial disclosures.
On Twitter@mitchelzoler
PHOENIX – A simple, five-element formula can help identify the patients undergoing heart surgery who face the greatest risk for a hospital readmission within 30 days following discharge from their index hospitalization.
The surgeons who developed this formula hope to use it in an investigational program that will target intensified management resources in postsurgical patients who face the highest readmission risk, to cut rehospitalizations and better improve their clinical status and quality of life.
The analysis that produced this formula also documented that the worst offender for triggering rehospitalizations following heart surgery is fluid overload, the proximate readmission cause for 23% of postsurgical patients, Dr. Arman Kilic said at the annual meeting of the Society of Thoracic Surgeons. The next most common cause was infection, which led to 20% of readmissions, followed by arrhythmias, responsible for 8% of readmissions, said Dr. Kilic, a thoracic surgeon at the University of Pennsylvania in Philadelphia.
Because fluid overload, often in the form of pleural effusion, is such an important driver of rehospitalizations, a more targeted management program would include better titration of diuretic treatment to patients following heart surgery, thoracentesis, and closer monitoring of clinical features that flag fluid overload such as weight.
“The volume overload issue is where the money is. If we can reduce that, it could really impact readmissions,” Dr. Kilic said in an interview.
An investigational program to target rehospitalization risk in heart surgery patients is planned at Johns Hopkins Hospital in Baltimore, where Dr. Kilic worked when he performed this analysis. Surgeons at Johns Hopkins are now in the process of getting funding for this pilot program, said Dr. John V. Conte Jr., professor of surgery and director of mechanical circulatory support at Johns Hopkins and a collaborator with Dr. Kilic on developing the risk formula.
“We’ll tailor postoperative follow-up. We’ll get high-risk patients back to the clinic sooner, and we’ll send nurse practitioners to see them to make sure they’re taking their medications and are getting weighed daily,” Dr. Conte said in an interview. “When a patient has heart surgery, they typically retain about 5-10 pounds of fluid. Patients with good renal function give up that fluid easily, but others are difficult to diurese. Many patients go home before they have been fully diuresed, and we need to follow these patients and transition them better to out-of-hospital care.”
He noted that other situations also come up that unnecessarily drive patients back to the hospital when an alternative and less expensive intervention might be equally effective. For example, some patients return to the hospital out of concern for how their chest wound is healing. Instead of being rehospitalized, such patients could be reassured by having them send a nurse a photo of their wound or by coming to an outpatient clinic.
“We need to engage more often with recently discharged patients,” Dr. Conte said in an interview. “Discharging them doesn’t mean separating them from the health care system; it should mean interacting with patients in a different way” that produces better outcomes and patient satisfaction for less money. Developing improved ways to manage recent heart surgery patients following discharge becomes even more critical later this year when, in July, the Centers for Medicare & Medicaid Services adds 30-day readmissions following coronary artery bypass grafting (CABG) to its list of procedures that can generate a penalty to hospitals if they exceed U.S. norms for readmission rates.
The risk model developed by Dr. Kilic, Dr. Conte, and their associates used data collected from 5,360 heart surgery patients treated at Johns Hopkins during 2008-2013. Nearly half the patients underwent isolated CABG, and 20% had isolated valve surgery. Overall, 585 patients (11%) had a hospital readmission within 30 days of their index discharge. One limitation of the analysis was it used data only on readmissions back to Johns Hopkins Hospital.
The researchers used data from three-quarters of the database to derive the risk formula, and from the remaining 25% of the database to validate the formula. A multivariate analysis of demographic and clinical characteristics that significantly linked with an elevated risk for readmissions identified five factors that independently made a significant contribution to readmission risk. The researchers assigned each of these five factors points depending on its relative contribution to readmission risk in the adjusted model: Severe chronic lung disease received 6 points; placement of a ventricular assist device received 5 points, while other types of heart surgery that was not CABG or valve surgery received 4 points (isolated CABG, isolated valve, or combined CABG and valve surgery received 0 points); development of acute renal failure postoperatively but before index discharge received 4 points; an index length of stay beyond 7 days received 4 points; and African American race received 3 points. The maximum number of points a patient could receive was 22.
Patients with a score of 0 had a 6% rate of a 30-day readmission; those with a score of 22 had a 63% readmission rate. For simplicity, Dr. Kilic suggested dividing patients into three categories based on their readmission risk score: Low-risk patients with a score of 0 had a readmission risk of 6%, medium-risk patients with a score of 1-10 had a readmission risk of 12%, and high-risk patients with a score of 11 or more had a readmission risk of 31%. The researchers found a 96% correlation when comparing these predicted readmission risk rates based on the derivation-subgroup analysis with the actual readmission rates seen in the validation subgroup of their database. The targeted risk-management program planned by Dr. Conte would primarily focus on high-risk patients.
Dr. Kilic and Dr. Conte said they had no relevant financial disclosures.
On Twitter@mitchelzoler
AT THE STS ANNUAL MEETING
Key clinical point: A risk score predicted which heart surgery patients faced the greatest risk for hospital readmission within 30 days of their index discharge.
Major finding: Patients with a 0 score had a 6% 30-day readmission rate; a high score of 22 linked with a 63% rate.
Data source: A review of 5,360 heart surgery patients treated at one U.S. center.
Disclosures: Dr. Kilic and Dr. Conte said they had no relevant financial disclosures.
