Faculty Bibliography

BACKGROUND:Falls are the leading source of injury and trauma-related hospital admissions for elderly adults in the USA. Elderly patients with a history of a fall have the highest risk of falling again, and the decision on whether to continue anticoagulation after a fall is difficult. To inform this decision, we evaluated the rate of recurrent falls and the impact of anticoagulation on outcomes. METHODS:All patients of age  ≥ 65 years and hospitalized for a fall in the first 6 months of 2013 and 2014 were identified in the nationwide readmission database, a nationally representative all-payer database tracking patient readmissions. Readmissions for a recurrent fall within 6 months, and mortality and bleeding injuries (intracranial hemorrhage, solid organ bleed, and hemothorax) during readmission were identified. Logistic regression evaluated factors associated with mortality on repeat falls. RESULTS:Of the 331,982 patients admitted for a fall, 15,565 (4.7%) were admitted for a recurrent fall within 6 months. The median time to repeat fall was 57 days (IQR 19-111 days), and 9.0% (1406) of repeat fallers were on anticoagulation. The rate of bleeding injury was similar regardless of anticoagulation status (12.8 vs. 12.7% not on anticoagulation, p = 0.97); however, among patients with a bleeding injury, those on anticoagulation had significantly higher mortality (21.5 vs. 6.9% not on anticoagulation, p < 0.01). CONCLUSION:Among patients hospitalized for a fall, 4.7% will be hospitalized for a recurrent fall within 6 months. Patients on anticoagulation with repeat falls do not have increased rates of bleeding injury but do have significantly higher rates of death with a bleeding injury. This information is essential to discuss with patients when deciding to restart their anticoagulation.

BACKGROUND:Under the Affordable Care Act, eligibility for Medicaid coverage was expanded to all adults with incomes up to 138% of the federal poverty level in states that participated. We sought to examine the national impact Medicaid expansion has had on insurance coverage for patients undergoing emergency general surgery (EGS) and the cost burden to patients. MATERIALS AND METHODS:The National Inpatient Sample (NIS) was used to identify adults ≥18 y old who underwent the 10 most burdensome EGS operations (defined as a combination of frequency, cost, and morbidity). Distribution of insurance type before and after Medicaid expansion and charges to uninsured patients was evaluated. Weighted averages were used to produce nationally representative estimates. RESULTS:A total of 6,847,169 patients were included. The percentage of uninsured EGS patients changed from 9.4% the year before Medicaid expansion to 7.0% after (P < 0.01), whereas the percentage of patients on Medicaid increased from 16.4% to 19.4% (P < 0.01). The cumulative charges to uninsured patients for EGS decreased from $1590 million before expansion to $1211 million after. CONCLUSIONS:In the first year of Medicaid expansion, the number of uninsured EGS patients dropped by 2.4%. The cost burden to uninsured EGS patients decreased by over $300 million.

BACKGROUND:Although Hartmann procedure is common for operatively managed acute diverticulitis, there is accumulating evidence that primary anastomosis with proximal small bowel diversion is safe, even in emergent cases. This study seeks to clarify the current adoption of primary anastomosis with proximal small bowel diversion among emergent, operatively managed cases of acute diverticulitis and compare outcomes between primary anastomosis with proximal small bowel diversion and Hartmann procedure. METHODS:Patients who underwent open, emergent Hartmann procedure or primary anastomosis with proximal small bowel diversion for a primary diagnosis of diverticulitis between 2005 and 2015 were identified in the database of the American College of Surgeons National Surgical Quality Improvement Program. Outcomes were compared with logistic regression adjusted for patient and operative characteristics. RESULTS:From 2005-2015 the proportion of primary anastomosis with proximal small bowel diversion decreased from 33% to 17% among emergent cases. Although mortality and complications were similar, primary anastomosis with proximal small bowel diversion resulted in a greater risk of returning to the operating room in emergent cases (odds ratio = 1.35, 95% confidence interval: 1.06-1.74). CONCLUSION:Despite previous suggestions of clinical equipoise, the adoption of primary anastomosis with proximal small bowel diversion for emergent, operatively managed acute diverticulitis among National Surgical Quality Improvement Program hospitals appears to be decreasing. Primary anastomosis with proximal small bowel diversion resulted in increased return to the operating room for emergent cases, suggesting that caution should be exercised in selecting primary anastomosis with proximal small bowel diversion for emergent cases.

IMPORTANCE:Reliance on prescription opioids for postprocedural analgesia has contributed to the opioid epidemic. With the implementation of electronic medical record (EMR) systems, there has been increasing use of computerized order entry systems for medication prescriptions, which is now more common than handwritten prescriptions. The EMR can autopopulate a default number of pills prescribed, and 1 potential method to alter prescriber behavior is to change the default number presented via the EMR system. OBJECTIVE:To investigate the association of lowering the default number of pills presented when prescribing opioids in an EMR system with the amount of opioid prescribed after procedures. DESIGN, SETTING, AND PARTICIPANTS:A prepost intervention study was conducted to compare postprocedural prescribing patterns during the 3 months before the default change (February 18 to May 17, 2017) with the 3 months after the default change (May 18 to August 18, 2017). The setting was a multihospital health care system that uses Epic EMR (Hyperspace 2015 IU2; Epic Systems Corporation). Participants were all patients in the study period undergoing 1 of the 10 most common operations and discharged by postoperative day 1. INTERVENTION:The default number of opioid pills autopopulated in the EMR when prescribing discharge analgesia was lowered from 30 to 12. MAIN OUTCOMES AND MEASURES:Linear regression estimating the change in the median number of opioid pills and the total dose of opioid prescribed was performed. Opioid doses were converted into morphine milligram equivalents (MME) for comparison. The frequency of patients requiring analgesic prescription refills was also evaluated. RESULTS:There were 1447 procedures (mean [SD] age, 54.4 [17.3] years; 66.9% female) before the default change and 1463 procedures (mean [SD] age, 54.5 [16.4] years; 67.0% female) after the default change. After the default change, the median number of opioid pills prescribed decreased from 30 (interquartile range, 15-30) to 20 (interquartile range, 12-30) per prescription (P < .001). The percentage of prescriptions written for 30 pills decreased from 39.7% (554 of 1397) before the default change to 12.9% (183 of 1420) after the default change (P < .001), and the percentage of prescriptions written for 12 pills increased from 2.1% (29 of 1397) before the default change to 24.6% (349 of 1420) after the default change (P < .001). Regression analysis demonstrated a decrease of 5.22 (95% CI, -6.12 to -4.32) opioid pills per prescription after the default change, for a total decrease of 34.41 (95% CI, -41.36 to -27.47) MME per prescription. There was no statistical difference in opioid refill rates (3.0% [4 of 135] before the default change vs 1.5% [2 of 135] after the default change, P = .41). CONCLUSIONS AND RELEVANCE:Lowering the default number of opioid pills prescribed in an EMR system is a simple, effective, cheap, and potentially scalable intervention to change prescriber behavior and decrease the amount of opioid medication prescribed after procedures.

BACKGROUND:The Model for End-Stage Liver Disease (MELD) score and ascites correlate with surgical morbidity and mortality. However, the MELD score does not account for ascites. We sought to evaluate whether the MELD score accurately risk stratifies patients with ascites. METHODS:We analyzed the American College of Surgeons National Surgical Quality Improvement Program (2005-2014) to examine the risk-adjusted morbidity and mortality of cirrhotic patients with and without ascites undergoing colectomy for diverticulitis. Patients were stratified by MELD score, and the presence of ascites and outcomes were compared between patients with and without ascites to the reference group of low MELD and no ascites. Multivariable logistic regression was used to control for demographic factors and comorbidities. RESULTS:A total of 16,877 colectomies were analyzed. For each MELD stratum, patients with ascites have increased risk of complications compared to those without ascites (P < 0.05 unless indicated): low MELD ascites OR 1.13, P = 0.69, moderate MELD no ascites OR 1.37, moderate MELD ascites OR 2.06, high MELD no ascites OR 1.93, and high MELD ascites OR 3.54. These trends hold true for mortality: low MELD ascites OR 2.91, P = 0.063, moderate MELD no ascites OR 1.47, moderate MELD ascites OR 5.62, high MELD no ascites OR 3.04, and high MELD ascites OR 9.91. CONCLUSION:Ascites predicts an increased risk for postoperative morbidity and mortality for cirrhotic patients undergoing colectomy for all MELD classifications. These findings suggest that the MELD score significantly underestimates postoperative risk as it does not account for ascites.

BACKGROUND:Ascites and the Model for End-Stage Liver Disease score have both been shown to independently correlate with surgical morbidity and mortality. We evaluated if incorporating the presence of ascites changed postoperative risk as assessed by the Model for End-Stage Liver Disease score. METHODS:Data originated from the National Surgical Quality Improvement Program database from 2005-2014. Patients undergoing hernia repair, adhesiolysis, and cholecystectomy were included. Univariate analysis and logistic regression stratified by Model for End-Stage Liver Disease score and presence of ascites was performed. RESULTS:A total of 30,391 patients were analyzed. When compared to low Model for End-Stage Liver Disease stratum without ascites, the presence of ascites predicted increased risk for complications (low Model for End-Stage Liver Disease with ascites odds ratio 3.22, 95% confidence interval [2.00-5.18], moderate Model for End-Stage Liver Disease with ascites odds ratio 3.70, 95% confidence interval [2.64-5.19], high Model for End-Stage Liver Disease with ascites odds ratio 6.38, 95% confidence interval [4.39-9.26]). These findings hold true for mortality as well (low Model for End-Stage Liver Disease with ascites odds ratio 9.40 95% confidence interval [3.53-25.01], moderate Model for End-Stage Liver Disease with ascites odds ratio 15.24 95% confidence interval [8.17-28.45], high Model for End-Stage Liver Disease with ascites odds ratio 28.56 95% confidence interval [15.43-52.88]). CONCLUSIONS:Ascites increased the risk of morbidity and mortality across multiple general surgery operations. Model for End-Stage Liver Disease may underestimate surgical risk in patients with ascites. Predictive models inclusive of ascites may more accurately predict the perioperative risk of these complex patients.

BACKGROUND:There is evidence to suggest outcomes may be related to surgeon experience or skill level. Lower extremity amputations are performed by both general surgeons (GSs) and vascular surgeons (VSs); however, the effect of specialty on postoperative outcome in below-knee amputation is not known. This retrospective study compares outcomes in below-knee amputations (BKA) between VS and GS. METHODS:Patients who underwent below-knee amputations between 2005 and 2014 were identified from the American College of Surgeons National Surgical Quality Improvement Project database. Data collected included patient demographics, comorbid conditions, and indication for procedures. Univariate and multivariate unconditional logistic regression models and linear regression models were employed to evaluate the associations between various outcomes and indications for surgery, emergency and teaching status, and surgical specialty. RESULTS:Amputations performed by GSs experienced an increased risk of developing pneumonia (odds ratio [OR] = 1.49, 95% confidence interval [CI]: 1.19-1.86), pulmonary embolism (OR = 2.10, 95% CI: 1.10-4.01), and sepsis (OR = 1.29, 95% CI: 1.05-1.59). When stratified by indications for BKA, similar outcomes were noted between GS and VS if indication for surgery was diabetes or peripheral vascular disease; however, there was increased risk of pneumonia (OR = 1.86, 95% CI: 1.26-2.74), sepsis (OR = 1.96, 95% CI: 1.39-2.75), and death (OR = 1.47, 95% CI: 1.04-2.07, P = 0.027) when GS performed BKA for infectious indications. Overall complications were higher when GS performed BKA emergently (OR = 1.17, 95% CI: 1.01-1.36). CONCLUSION/CONCLUSIONS:There are less postoperative complications when VSs performed BKA for infectious indications, during emergencies, and at nonteaching hospitals. Clinicians should consider vascular consultation for these specific scenarios.

BACKGROUND:Current guidelines for small bowel obstruction (SBO) recommend a limited trial of nonoperative management of no more than 3-5 d. For patients requiring surgery, it is uncertain if sociodemographic factors are associated with disparities in the duration of the trial of nonoperative therapy. METHODS:The Healthcare Cost and Utilization Project National Inpatient Sample from 2012 to 2014 was queried for discharges with a primary diagnosis of SBO. Primary outcomes of interest were the effects of sociodemographic factors, including race, insurance status, and income on the rate of receiving any operative management for SBO, and subsequently, among patients managed surgically, the risk of operative delay, defined as operative management ≥ 5 d after admission. We did this by using logistic hierarchical generalized linear models, accounting for hospital clustering and adjusted for sex, age, comorbidity, and hospital factors. RESULTS:Of the 589,850 admissions for SBO between 2012 and 2014, 22.0% underwent operations. Overall, 26.2% were non-White, including 12.2% Black and 8.6% Hispanic patients, and the majority (56.0%) had Medicare insurance coverage. Income quartiles were evenly distributed across the overall study population. In adjusted logistic regression, operative delay was associated with increased odds of in-hospital mortality (odds ratio 1.30 95% confidence interval [1.10, 1.54]). Adjusted for patient and hospital factors, Black patients were significantly more likely to receive operations for SBO, whereas Medicaid and Medicare patients were significantly less likely. However, Black, Medicaid, and Medicare patients who were managed operatively were significantly more likely to have an operative delay of 5 or more d. There was no significant association between income and operative management in adjusted regression models. CONCLUSIONS:Significant disparities in the operative management were based on race and insurance status. Further research is warranted to understand the causes of, and solutions to, these sociodemographic disparities in care.

BACKGROUND:Small bowel obstruction is common and often requires surgical management. Simple preoperative models are lacking to predict post-operative complications after surgical management of adhesive small bowel obstruction. METHODS:We retrospectively analyzed data from 15,036 patients who underwent open lysis of adhesions for small bowel obstruction from 2005 to 2013 using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Predictors of post-operative complications were identified using logistic regression. Predictive models were compared using areas under the receiver operating characteristic curves (AUROC). RESULTS:A three-parameter model was constructed, termed FAS: Functional status, American Society of Anesthesiologists (ASA) classification, and prior Sepsis. FAS predicted post-operative complications with odds ratio (OR) 1.11, 95% CI (1.10, 1.12), P < 0.001 and AUROC of 0.69, 95% CI (0.67, 0.70). CONCLUSIONS:FAS predicts post-operative complications after open lysis of adhesions using three readily available clinical parameters.

BACKGROUND:Small bowel obstruction (SBO) represents roughly 15% of admissions by general surgeons. Management of SBO relies heavily on provider judgment, including decisions on how long to try nonsurgical management and whether to use a laparoscopic or open approach when surgery is needed. Given the subjective nature of these decisions, it is unknown if patient race influences management of SBO. STUDY DESIGN:The National Surgical Quality Improvement Program was used to identify patients who underwent adhesiolysis or small bowel resection for adhesive SBO between 2010 and 2015 (n = 13,896). Adjusted logistic regression models incorporating patient comorbidity, American Society of Anesthesiologists (ASA) class, and emergency status were used to analyze odds of receiving surgery after 5 days from hospital admission (Eastern Association for the Surgery of Trauma guidelines) and of undergoing an open operation. RESULTS:Patients who waited more than 5 days for a procedure had greater adjusted odds of postoperative complication (odds ratio [OR] 1.56 95% CI 1.37 to 1.79) compared with those waiting 5 days or less. Similarly, open procedures had higher odds of complication compared with laparoscopic (OR 2.31 95% CI 2.00 to 2.68). Regression analysis demonstrated that black patients were significantly more likely than white patients to wait more than 5 days for surgery (OR 1.31 95% CI [1.13-1.53]) and undergo open surgery (OR 1.56, 95% CI 1.36 to 1.79). There was no statistical difference for Hispanics patients waiting more than 5 days (OR 0.98, 95% CI 0.73 to 1.31) or receiving open surgery (OR 0.84, 95% CI 0.70 to 1.01) compared with white patients. CONCLUSIONS:Clinical decisions regarding SBO management differ based on patient race. Future studies focusing on the surgical decision-making process and the influence of bias are needed.