Cost of Care in Open Cystectomy Patients Across Time and Space: Does it matter?

BACKGROUND: Many variables may affect the cost of open radical cystectomy (RC) care, including surgical approach, diversion type, patient comorbidities, and postoperative complications. OBJECTIVE: To determine factors associated with changes in cost of care following open radical cystectomy (ORC) for bladder cancer using the National Inpatient Sample (NIS). METHODS: Patients in the NIS with a diagnosis of bladder cancer who underwent ORC with ileal conduit from 2012–2017 using ICD-9-CM and ICD-10-CM codes were identified. Baseline demographics including age, race, region, postoperative complications, and length of stay were obtained. Univariable and multivariable logistic regression were used to identify factors associated with cost variation including demographics, clinical characteristics, surgical factors, and discharge quarter (Q1-Q4). RESULTS: 5,189 patients were included in the analysis, with 4,379 at urban teaching hospitals. On multivariable regression analysis, female sex [$1,734 ($1,024–2,444) p < 0.001)], a greater Elixhauser comorbidity score [$93 ($62–124), p < 0.001], presence of any inpatient complication [$1,531 ($894–2,168), p < 0.001], and greater length of stay [$1,665 ($1,536–1,793), p < 0.001] were associated with a greater cost of hospitalization. Discharge in Q3 (July to September) relative to Q2 (April to June) was associated with a higher cost [$1,113 ($292–1,933), p = 0.008. Trends were similar at urban non-teaching and rural hospitals, except discharge quarter was not associated with a significant change in cost. CONCLUSIONS: Significant differences in cost of ORC with ileal conduit exist with respect to patient sex, medical comorbidities, and discharge timing. These differences may relate to greater disease burden in female patients, patient complexity, and variation in postoperative care in academic programs.

For Patients With Isolated Cleft Palate Does Revision Palatoplasty Have an Increased Risk of Inpatient Complication Compared to Primary Palatal Repair?

Objective: The purpose of this study was to determine whether revision palatoplasty was associated with increased rates of inpatient complication and wound dehiscence compared to primary palatal repair. Materials and Methods: This was a retrospective study of patients with isolated cleft palate treated with primary palatoplasty or revision surgery for fistula repair. The records were obtained from the Kids’ Inpatient Database between 2000 and 2014. The primary predictor was the type of surgery, classified as either primary or revision palatoplasty. Secondary predictors included demographics and comorbidities. Primary study outcomes were the postoperative complication and dehiscence rates as noted during the hospitalization course. The secondary outcomes related to health care utilization as measured through length of stay (LOS) and hospital charges. Results: A total of 5357 total admissions (95.5% primary, 4.5% revision) were included in the final sample. Fistula repairs (odds ratio = 14.37, P < .01) had significantly greater odds of wound dehiscence. The rates of inpatient complication ranged from 3.5% to 3.7%, and there were no significant differences between primary and revision surgery ( P = .82). Complications were independently associated with insurance status and congenital anomalies. Complications and wound dehiscence both significantly increased the LOS and the hospital charges. Fistula repairs had a shorter mean LOS ( P = .02), however this did not translate into cost savings ( P = .60). Conclusions: Although the rates of inpatient complications were not significantly different, revision palatoplasty was associated with a greater odds of wound dehiscence. Failure of a primary repair may portend an increased risk of wound failure with subsequent surgeries.

Comparing Inpatient Complication Rates between Octogenarians and Nonagenarians Following Primary and Revision Total Hip Arthroplasty in a Nationally Representative Sample 2010–2014

We compared inpatient postoperative complication rates between octogenarians and nonagenarians undergoing primary and revision total hip arthroplasty (THA). We used inpatient admission data from 2010–2014 from the Nationwide Inpatient Sample (NIS). We compared the rates at which nonagenarians and octogenarians developed each complication in the inpatient setting following both primary THA (PTHA) and revision THA (RTHA). A total of 40,944 inpatient admissions were included in our study which extrapolates to a national estimate of 199,793 patients. A total of 185,799 (93%) were octogenarians and 13,994 (7%) were nonagenarians. PTHA was performed on 155,669 (78%) and RTHA was performed on 44,124 (22%) of the patients. Nonagenarians undergoing PTHA required transfusions significantly more frequently (33.13% v. 24.0%, p < 0.001) and developed urinary tract infection (5.14% v. 3.92%, p = 0.012) and acute kidney injury (5.50% v. 3.57%, p < 0.001) significantly more frequently than octogenarians. Nonagenarians undergoing RTHA required transfusions significantly more frequently (51.43% v. 41.46%, p < 0.001) and developed urinary tract infection (19.66% v. 11.73%, p < 0.001), acute kidney injury (13.8% v. 9.66%, p < 0.001), pulmonary embolism (1.24% v. 0.67%, p = 0.031), postoperative infection (1.89% v. 1.11%, p = 0.023), sepsis (3.59% v. 2.43%, p = 0.021) and other postoperative shock (1.76% v. 1.06%, p = 0.036) significantly more frequently than octogenarians. Nonagenarians undergoing RTHA also had a significantly higher inpatient mortality rate (3.28% v. 1.43%, p < 0.001) than octogenarians. Orthopedic surgeons and primary care providers can use these findings to help counsel both their octogenarian and nonagenarian patients preoperatively when considering THA. Our analysis can help these patients better understand expected inpatient complication rates and assist them in deciding whether to pursue surgical intervention when applicable.

A Comparative Analysis of Open versus Endovascular Techniques for Management of Non-Aortic Cervicothoracic Arterial Injuries

The objective of this study is to describe the contemporary management of proximal upper extremity and neck arterial injuries by comparing open and endovascular repair at a single institution. This is a retrospective study of 22 patients that sustained subclavian, axillary, and carotid artery injuries from 2011 to 2016 that were managed with open or endovascular repair. There were nine subclavian, eight axillary, and five carotid artery injuries of which 10 (45.5%) underwent endovascular repair and 12 (54.5%) underwent open repair. There was no statistically significant difference between the groups including injury severity score or preoperative hypotension. There were no deaths in the endovascular group, and three (25.0%) deaths in the open group. All patients in the endovascular group were discharged home. In the open group, seven (58.3%) patients had at least one inpatient complication with a mean of 1.1 (standard deviation 1.4) complications per patient. In the endovascular group, there were three (30.0%) patients with inpatient complications and a mean of 0.4 (standard deviation 0.7) complications per patient (P = 0.18). Endovascular management of nonaortic cervicothoracic arterial injuries was successfully performed in hypotensive patients and patients with other life threatening traumatic injuries. Further studies are warranted to look at long-term patency of these repairs and to help develop a protocol to guide decision-making in the management of cervicothoracic injuries.

Does Surveillance Bias Influence the Validity of Measures of Inpatient Complications? A Systematic Review

Surveillance bias may threaten the accuracy of inpatient complication measures. A systematic literature review was conducted to examine whether surveillance bias influences the validity of selected Patient Safety Indicator– and health care associated infection–related measures. Ten venous thromboembolism (VTE) articles were identified: 7 trauma related, 3 postoperative, and 1 central line–associated bloodstream infection (CLABSI) article. Nine VTE articles found positive associations between deep vein thrombosis imaging and VTE diagnoses. Because imaging also may be symptom driven, most studies performed additional analyses to corroborate findings. Six trauma-related and 2 postoperative VTE studies concluded that surveillance bias was present, the latter based on circumstantial evidence. The non-VTE study found a significant positive correlation between surveillance aggressiveness and intensive care unit CLABSI rates. Even considering VTE, relatively little is known about the impact of surveillance bias on inpatient complication measures. Given the implications of misclassifying hospitals on quality, this issue requires further investigation using more direct measurement methods.