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1.
Lucas W. Thornblade Yongwoo D. Seo Tracy Kwan Jane H. Cardoso Eric Pan Gregory Dembo Raymond S. W. Yeung James O. Park 《Journal of gastrointestinal surgery》2018,22(6):981-988
Background
Enhanced recovery after surgery (ERAS) protocols are now commonplace in many fields of surgery, but only limited data exists for their use in hepatobiliary surgery. We implemented standardized ERAS protocols for all open hepatectomies and replaced thoracic epidurals with a transversus abdominis plane (TAP) block.Methods
We performed a retrospective cohort study of all patients undergoing open hepatectomy during the 14 months before and 19 months after implementation of an ERAS protocol at our institution (January 2014–September 2016). Trained abstractors reviewed charts for patient demographics, perioperative details, and healthcare utilization. All nursing-reported visual analog scale pain scores were sampled to identify patients with uncontrolled pain (daily mean score?>?5). Outcomes included length of stay (LOS), costs, and 30-day readmission.Results
A total of 127 patients (mean age 54.6?±?13.0 years, 44% female) underwent open liver resection (69 [54%] after ERAS implementation). ERAS protocols were associated with significantly lower rates of ICU admission (47 vs. 13%, p?<?0.001), shorter LOS (median 5.3 vs. 4.3 days, p?=?0.007), and lower median costs ($3566 less, p?=?0.03). Readmission remained low throughout the study period (5% pre-ERAS, 4% during ERAS, p?=?0.83). Rates of uncontrolled pain were either the same or better after ERAS implementation through post-operative day #3 (41% pre-ERAS, 23% during ERAS, p?=?0.03).Discussion
The use of TAP block for hepatectomy as part of an ERAS protocol is associated with improved quality and cost of care. Surgeons performing liver resections should consider standardization of evidence-based best practices in all patients.2.
Gregg Nelson Lawrence N. Kiyang Ellen T. Crumley Anderson Chuck Thanh Nguyen Peter Faris Tracy Wasylak Carlota Basualdo-Hammond Susan McKay Olle Ljungqvist Leah M. Gramlich 《World journal of surgery》2016,40(5):1092-1103
Background
Enhanced recovery after surgery (ERAS) colorectal guideline implementation has occurred primarily in standalone institutions worldwide. We implemented the guideline in a single provincial healthcare system, and our study examined the effect of the guideline on patient outcomes [length of stay (LOS), complications, and 30-day post-discharge readmissions] across a healthcare system.Methods
We compared pre- and post-guideline implementation in consecutive elective colorectal patients, ≥18 years, from six Alberta hospitals between February 2013 and December 2014. Participants were followed up to 30 days post discharge. We used summary statistics, to assess the LOS and complications, and multivariate regression methods to assess readmissions and to estimate cost impacts.Results
A total of 1333 patients (350 pre- and 983 post-ERAS) were analysed. Of this number, 55 % were males. Median overall guideline compliance was 39 % in pre- and 60 % in post-ERAS patients. Median LOS was 6 days for pre-ERAS compared to 4.5 days in post-ERAS patients with the longest implementation (p value <0.0001). Adjusted risk ratio (RR) was 1.71, 95 % CI 1.09–2.68 for 30-day readmission, comparing pre- to post-ERAS patients. The proportion of patients who developed at least one complication was significantly reduced, from pre- to post-ERAS, difference in proportions = 11.7 %, 95 % CI 2.5–21.0, p value: 0.0139. The net cost savings attributable to guideline implementation ranged between $2806 and $5898 USD per patient.Conclusion
The findings in our study have shown that ERAS colorectal guideline implementation within a healthcare system resulted in patient outcome improvements, similar to those obtained in smaller standalone implementations. There was a significant beneficial impact of ERAS on scarce health system resources.3.
Tilda Hahl Pipsa Peromaa-Haavisto Pekka Tarkiainen Otto Knutar Mikael Victorzon 《Obesity surgery》2016,26(3):505-511
Background
Enhanced recovery after surgery (ERAS) programs are well established for patients undergoing colorectal surgery. Relatively little is known about ERAS following bariatric surgery in general or following laparoscopic Roux-en-Y gastric bypass (LRYGB) in particular.Patients and Methods
This is a prospective, observational study of 388 consecutive patients that underwent LRYGB with ERAS in a general hospital. The ERAS protocol included standardizations of pre-, intra-, and postoperative modalities in order to reduce the stress response of the patients. Primary outcome measures were length of stay (LOS), postoperative morbidity, readmissions, and reoperations.Results
Mean (SD) baseline body mass index (BMI) and age was 46.4 (6.7)?kg/m2 and 45.1 (11.2)?years, respectively. Fifty-four percent of the patients were on medication for hypertension (HT) and 38 % for type 2 diabetes mellitus (DM2). Mean (SD) and median (range) surgical time was 73.8 (16.9) and 65 (40–143)?min, respectively. Mean LOS was 1.3 days (1.1), median 1 day (1–14). Of all patients, 322 (83 %) were discharged on the first postoperative day (POD). Overall morbidity was 9.8 %. Three patients (0.8 %) had life-threatening complications. The readmission rate was 4.9 %, and 3.4 % of the patients had to be reoperated. With a follow-up rate of 83 % at 1 year, total weight loss (TWL) was 31 % and excess BMI loss (EBMIL) 70 %. Total remission of DM2 and HT was achieved in 70 and 42 % of the patients, respectively.Conclusion
Enhanced recovery following LRYGB with ERAS programs is possible and safe even in a low volume, general hospital. Early discharge does not increase postoperative morbidity or readmissions.4.
Purpose
Giant ventral hernia repair is associated with a high risk of postoperative morbidity and prolonged length of stay (LOS). Enhanced recovery (ERAS) measures have proved to lead to decreased morbidity and LOS after various surgical procedures, but never after giant hernia repair. The current study prospectively examined the results of implementation of an ERAS pathway including high-dose preoperative glucocorticoid, and compared the outcome with patients previously treated according to standard care (SC).Methods
Consecutive patients who underwent giant ventral hernia repair were included. Pain, nausea and fatigue were registered prospectively in all patients treated according to ERAS, as well as continuous measurement of transcutaneous capillary oxygen saturation. Postoperative morbidity and LOS were compared between patients treated according to ERAS and a historic group treated with SC.Results
A total of 32 patients were included. Postoperative LOS was decreased after the introduction of the ERAS pathway compared with SC (median 3.0 vs. 5.5 days, P = 0.003). Scores of pain, nausea and fatigue were low, while mean oxygen saturation during the first three postoperative days was 0.92. There were no differences when comparing readmission (5 vs. 2, P = 0.394), postoperative complications (7 vs. 4, P = 0. 458), or reoperation (5 vs. 1, P = 0.172) in ERAS versus controls.Conclusions
The current study suggests that an ERAS pathway including preoperative high-dose glucocorticoid may lead to low scores of pain, fatigue and nausea after giant ventral hernia repair with reduced LOS compared with patients treated according to SC.5.
Purpose
To report 90-day complication rates following radical cystectomy (RC) with enhanced recovery after surgery (ERAS) protocol.Methods
All consecutive patients who underwent open RC with ERAS protocol from 2012 to 2014 were included. The protocol includes no bowel preparation or NGT, early feeding, predominantly non-narcotic pain management and μ-opioid antagonists. Non-consenting and lost to follow-up patients were excluded. All patients were closely followed up, and 90-day complication (Clavien–Dindo grading), readmission and emergency room (ER) visits were prospectively recorded.Results
One hundred and sixty-nine cases with a median age of 71 years were included in the study. 90-Day major and minor complication rates were 24.3 and 53.9 %, respectively. The most common complications were infectious and gastrointestinal. The 90-day ER visit rate was 37.9 %, whereas the readmission rate was 29.6 %. The most common cause of hospital readmission and ER visits was infections.Conclusion
Radical cystectomy and urinary diversion with enhanced recovery protocol is a morbid surgery. The most common complication, cause of ER visit and readmission is yet infections. Further studies on methods to decrease these rates are underway.6.
Background
The Enhanced Recovery After Surgery (ERAS) program has been shown to reduce length of stay (LOS) in colorectal surgical patients in randomized trials. The impact outside of trial settings, or in subgroups of patients excluded from trials such as individuals with diabetes, is uncertain. We conducted this study to evaluate the impact of ERAS implementation in Alberta, Canada.Methods
This is a retrospective cohort study and interrupted time series analysis using linked administrative data to examine LOS and postoperative outcomes in the 12 months pre- and post-implementation of ERAS in 2013 for all adults undergoing elective colorectal surgery.Results
Of 2714 patients (mean age 60.4 years, 55% men) with similar demographics and comorbidity profiles in the pre/post-ERAS time periods, LOS was significantly shorter post-ERAS (8.5 vs. 9.5 days, p?=?0.01; ? 0.84 days [95% CI ? 0.04 to ? 1.64 days] after adjustment for age, sex, Charlson comorbidity score, procedure type, surgical approach, and hospital). However, interrupted time series demonstrated no significant level change (p?=?0.30) or change in slope (p?=?0.63) with ERAS implementation, consistent with continuation of an underlying secular trend of reductions in LOS over time. There were no significant differences (in multivariate analysis or ITS) in risk of 30-day death/readmission (14.3% post vs. 13.5% pre-ERAS, aOR 1.12, 95% CI 0.89–1.40), 30-day death/ED visit (27.2% post vs. 30.0% pre, aOR 0.93, 95% CI 0.78–1.10), or 30-day death/readmission/ED visit (27.8% post vs. 30.6% pre, aOR 0.93, 95% CI 0.78–1.10). The 428 patients with diabetes had longer LOS but exhibited no significant difference post- versus pre-ERAS (10.7 vs. 11.6 days, p?=?0.53; p?=?0.56 for level change and p?=?0.66 for slope change on ITS).Conclusion
Although there was a secular trend toward decreasing LOS over time in Alberta, ERAS implementation was not associated with statistically significant changes in LOS or postoperative outcomes for all colorectal surgery patients or for those with diabetes. Our study highlights the importance of evaluating system changes (for both uptake and outcomes) rather than assuming trial benefits will translate directly into practice. Interventions to improve LOS and postoperative outcomes for patients with diabetes undergoing colorectal surgery are still needed even in the ERAS era.7.
Ola S. Ahmed Ailín C. Rogers Jarlath C. Bolger Achille Mastrosimone William B. Robb 《Journal of gastrointestinal surgery》2018,22(6):964-972
Background
Enhanced recovery after surgery (ERAS) guidelines, fast-track protocols, and alternative clinical pathways have been widely promoted in a variety of disciplines leading to improved outcomes in post-operative morbidity and length of stay (LOS). This meta-analysis assesses the implications of standardized management protocols in bariatric surgery.Methods
The PRISMA guidelines were adhered to. Databases were searched with the application of pre-defined inclusion and exclusion criteria. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI). Individual protocols and surgical approaches were assessed through subgroup analysis, and sensitivity analysis of methodological quality was performed.Results
A total of 1536 studies were screened; 13 studies were eventually included for meta-analysis involving a total of 6172 patients. Standardized perioperative techniques were associated with a savings of 19.5 min in operative time (p <?0.01), as well as a LOS which was shortened by 1.5 days (p <?0.01). Pooled post-operative morbidity rates also favored enhanced recovery care protocols (OR 0.7%, 95% CI 0.6–0.9%, p <?0.01).Conclusion
Bariatric surgery involves a complex cohort of patients who require high-quality evidence-based care to improve outcomes. Consensus guidelines on the feasibility of ERAS and alternative clinical pathways are required in the setting of bariatric surgery.8.
T. D. Cunningham B. C. Martin S. C. DeShields C. C. Romero 《Osteoporosis international》2016,27(10):2979-2988
Summary
This study compared length of stay, hospital costs, 30-day readmission, and mortality for patients admitted primarily for osteoporotic fractures to those admitted for five other common health conditions. The results indicated that osteoporotic fractures were associated with highest hospital charges and the second highest hospital stay after adjusting for confounders.Introduction
This study aimed to compare the effect of osteoporotic fractures and other common hospitalized conditions in both men and women age 55 years and older on a large in-patient sample.Methods
De-identified patient level and readmission and transfer data from the Virginia Health Information (VHI) system for 2008 through 2014 were merged. Logistic regression models were used to assess mortality and 30-day readmission, while generalized linear models were fitted to assess LOS and hospital charges.Results
After adjustment for confounders, osteoporotic fractures had the second longest LOS (6.0 days, 95 % CI?=?5.9–6.0) and the highest average total hospital charges ($47,386.0, 95 % CI?=?$46,707.0–$48,074.0) compared to the other five common health problems.Conclusion
Recognizing risk and susceptibility to osteoporotic fractures is an important motivator for individual behaviors that mitigate this disease. Furthermore, acknowledging the economic impact and disabling burden of osteoporotic fractures on society are compelling reasons to promote bone health as well as to prevent, diagnose, and manage osteoporosis.9.
Monica Sethi Karan Patel Jonathan Zagzag Manish Parikh John Saunders Aku Ude-Welcome Eduardo Somoza Bradley Schwack Marina Kurian George Fielding Christine Ren-Fielding 《Journal of gastrointestinal surgery》2016,20(2):244-252
Background
Thirty-day readmission post-bariatric surgery is used as a metric for surgical quality and patient care. We sought to examine factors driving 30-day readmissions after laparoscopic sleeve gastrectomy (LSG).Methods
We reviewed 1257 LSG performed between March 2012 and June 2014. Readmitted and nonreadmitted patients were compared in their demographics, medical histories, and index hospitalizations. Multivariable regression was used to identify risk factors for readmission.Results
Forty-five (3.6 %) patients required 30-day readmissions. Forty-seven percent were readmitted with malaise (emesis, dehydration, abdominal pain) and 42 % with technical complications (leak, bleed, mesenteric vein thrombosis). Factors independently associated with 30-day readmission include index admission length of stay (LOS) ≥3 days (OR 2.54, CI?=?[1.19, 5.40]), intraoperative drain placement (OR 3.11, CI?=?[1.58, 6.13]), postoperative complications (OR 8.21, CI?=?[2.33, 28.97]), and pain at discharge (OR?8.49, CI?=?[2.37, 30.44]). Patients requiring 30-day readmissions were 72 times more likely to have additional readmissions by 6 months (OR?72.4, CI?=?[15.8, 330.5]).Conclusions
The 30-day readmission rate after LSG is 3.6 %, with near equal contributions from malaise and technical complications. LOS, postoperative complications, drain placement, and pain score can aid in identifying patients at increased risk for 30-day readmissions. Patients should be educated on postoperative hydration and pain management, so readmissions can be limited to technical complications requiring acute inpatient management.10.
Trit Garg Ulysses Rosas Daniel Rogan Harrison Hines Homero Rivas John M. Morton Dan Azagury 《Journal of gastrointestinal surgery》2016,20(11):1797-1801
Introduction
Readmissions are an important quality metric for surgery. Here, we compare characteristics of readmissions across laparoscopic Rouxen-Y gastric bypass (LRYGB), sleeve gastrectomy (LSG), and adjustable gastric band (LAGB).Methods
Demographic, intraoperative, anthropometric, and laboratory data were prospectively obtained for 1775 patients at a single academic institution. All instances of readmissions within 1 year were recorded. Data were analyzed using STATA, release 12.Results
For the 1775 patients, 113 (6.37 %) were readmitted. Mean time to readmission was 52.1 days. Of all the readmissions, 64.6 % were within 30 days, 22.1 % from 30 to 90 days, 1.77 % from 90 to 180 days, and 11.5 % from 180 to 365 days. Incidence of 30-day readmissions varied across surgeries (LRYGB: 7.17 %; LAGB: 3.05 %; LSG: 4.25 %, p?=?0.04). Time to readmission varied as well, with 90.0 % of LSG and 80.0 % of LABG patients within the first 30 days, versus 60.8 % of LRYGB (p?=?0.02). The most common causes of readmissions were gastrointestinal issues related to index procedure (34.5 %) and did not vary across surgeries. In multivariable logistic regression, index hospital length of stay (LOS) was associated with readmission (OR?=?1.07, 95 % CI 1.02–1.13, p?=?0.01).Conclusions
Readmissions after bariatric surgery are associated with high index hospital LOS, and a measureable proportion of procedure-related readmissions can occur up to 1 year, especially for LRYGB.11.
Piotr Major Michał Wysocki Grzegorz Torbicz Natalia Gajewska Alicja Dudek Piotr Małczak Michał Pędziwiatr Magdalena Pisarska Dorota Radkowiak Andrzej Budzyński 《Obesity surgery》2018,28(2):323-332
Background
Laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LRYGB) are most commonly performed bariatric procedures. Laparoscopic approach and enhanced recovery after surgery (ERAS) protocols managed to decrease length of hospital and morbidity. However, there are patients in whom, despite adherence to the protocol, the length of stay (LOS) remains longer than targeted. This study aimed to assess potential risk factors for prolonged LOS and readmissions.Methods
The study was a prospective observation with a post-hoc analysis of bariatric patients in a tertiary referral university teaching hospital. Inclusion criteria were undergoing laparoscopic bariatric surgery. Exclusion criteria were occurrence of perioperative complications, prior bariatric procedures, and lack of necessary data. The primary endpoints were the evaluations of risk factors for prolonged LOS and readmissions.Results
Median LOS was 3 (2–4) days. LOS > 3 days occurred in 145 (29.47%) patients, 79 after LSG (25.82%) and 66 after LRYGB (35.48%; p = 0.008). Factors significantly prolonging LOS were low oral fluid intake, high intravenous volume of fluids administered on POD0, and every additional 50 km distance from habitual residence to bariatric center. The risk of hospital readmission rises with occurrence of intraoperative adverse events and low oral fluid intake on the day of surgery on.Conclusions
Risk factors for prolonged LOS are low oral fluid intake, high intravenous volume of fluids administered on POD0, and every additional 50 km distance from habitual residence. Risk factors for hospital readmission are intraoperative adverse events and low oral fluid intake on the day of surgery.12.
C.?S.?Voskuilen E.?E.?Fransen?van de?Putte J.?Bloos-van?der?Hulst E.?van?Werkhoven W.?M.?de?Blok B.?W.?G.?van?Rhijn S.?Horenblas R.?P.?Meijer
Purpose
Cystectomy for bladder cancer is associated with a high risk of postoperative complications. Standardized perioperative protocols, such as enhanced recovery after surgery (ERAS) protocols, aim to improve postoperative outcome. Postoperative feeding strategies are an important part of these protocols. In this two-centre study, we compared complications and length of hospital stay (LOS) between an ERAS protocol with early oral nutrition and a protocol with early enteral feeding with a Bengmark nasojejunal tube.Methods
We retrospectively reviewed 154 consecutive patients who underwent cystectomy for bladder cancer in two hospitals (Hospital A and B) between 2014 and 2016. Hospital A uses an ERAS protocol (n = 45), which encourages early introduction of an oral diet. Hospital B uses a fast-track protocol comprising feeding with a Bengmark nasojejunal tube (Bengmark-protocol, n = 109). LOS and complications according to Clavien classification were compared between protocols.Results
Overall 30-day complication rates in the ERAS and Bengmark protocol were similar (64.4 and 67.0%, respectively; p = 0.463). The rate of postoperative ileus (POI) was significantly lower in the Bengmark protocol (11.9% vs. 34.4% in the ERAS protocol, p = 0.009). This association remained significant after adjustment for other variables (odds ratio 0.32, 95% confidence interval 0.11–0.96; p = 0.042). Median LOS did not differ significantly between protocols (10 days vs. 11 days in the ERAS and Bengmark protocols, respectively; p = 0.861).Conclusions
Early oral nutrition in Hospital A was well tolerated. However, the Bengmark protocol was superior with respect to occurrence of POI. A prospective study may clarify whether the lower rate of POI was due to the use of early nasojejunal tube feeding or other reasons.13.
Background
Enhanced recovery after surgery (ERAS) protocols or laparoscopic technique has been applied in various surgical procedures. However, the clinical efficacy of combination of the two methods still remains unclear. Thus, our aim was to assess the role of ERAS protocols in laparoscopic abdominal surgery.Methods
We performed a systematic literature search in various databases from January 1990 to October 2017. The results were analyzed according to predefined criteria.Results
In the present meta-analysis, the outcomes of 34 comparative studies (15 randomized controlled studies and 19 non-randomized controlled studies) enrolling 3615 patients (1749 in the ERAS group and 1866 in the control group) were pooled. ERAS group was associated with shorter hospital stay (WMD ??2.37 days; 95% CI ??3.00 to ??1.73; P 0.000) and earlier time to first flatus (WMD ??0.63 days; 95% CI ??0.90 to ??0.36; P 0.000). Meanwhile, lower overall postoperative complication rate (OR 0.62; 95% CI 0.51–0.76; P 0.000) and less hospital cost (WMD 801.52 US dollar; 95% CI ??918.15 to ??684.89; P 0.000) were observed in ERAS group. Similar readmission rate (OR 0.73, 95% CI 0.52–1.03, P 0.070) and perioperative mortality (OR 1.33; 95% CI 0.53–3.34; P 0.549) were found between the two groups.Conclusions
ERAS protocol for laparoscopic abdominal surgery is safe and effective. ERAS combined with laparoscopic technique is associated with faster postoperative recovery without increasing readmission rate and perioperative mortality.14.
Jennifer Jolley Daniel Lomelin Anton Simorov Carl Tadaki Dmitry Oleynikov 《Surgical endoscopy》2016,30(9):3783-3791
Background
Surgical procedures have a learning curve regarding the number of cases required for proficiency. Consequently, involvement of less experienced resident surgeons may impact patients and the healthcare system. This study examines basic and advanced laparoscopic procedures performed between 2010 and 2011 and evaluates the resident surgeon participation effect.Methods
Basic laparoscopic procedures (BL), appendectomy (LA), cholecystectomy (LC), and advanced Nissen fundoplication (LN) were queried from the American College of Surgeons National Surgical Quality Improvement Program database. Cases were identified using Current Procedural Terminology codes. Analyses were performed using IBM SPSS Statistics v.22, α-level = 0.05. Multiple logistic regression was used, accounting for age, race, gender, admission status, wound classification, and ASA classification.Results
In total, 71,819 surgeries were reviewed, 66,327 BL (37,636 LC and 28,691 LA) and 5492 LN. Median age was 48 years for LC and 37 years for LA. In sum, 72.2 % of LC and 49.5 % of LA patients were female. LN median age was 59 years, and 67.7 % of patients were female. For BL, resident involvement was not significantly associated with mortality, morbidity, and return to the OR. Readmission was not related to resident involvement in LC. In LA, resident-involved surgeries had increased readmission and longer OR time, but decreased LOS. In LC, resident involvement was associated with longer LOS and OR time. Resident involvement was not a significant factor in the odds of mortality, morbidity, return to OR, or readmission in LN. Surgeries involving residents had increased odds of having longer LOS, and of lengthier surgery time.Conclusions
We demonstrate resident involvement is safe and does not result in poorer patient outcomes. Readmissions and LOS were higher in BL, and operative times were longer in all surgeries. Resident operations do appear to have real consequences for patients and may impact the healthcare system financially.15.
16.
Gaëtan-Romain Joliat Ismaïl Labgaa Martin Hübner Catherine Blanc Anne-Claude Griesser Markus Schäfer Nicolas Demartines 《World journal of surgery》2016,40(10):2441-2450
Background
Enhanced recovery after surgery (ERAS) programs have been shown to ease the postoperative recovery and improve clinical outcomes for various surgery types. ERAS cost-effectiveness was demonstrated for colorectal surgery but not for liver surgery. The present study aim was to analyze the implementation costs and benefits of a specific ERAS program in liver surgery.Methods
A dedicated ERAS protocol for liver surgery was implemented in our department in July 2013. The subsequent year all consecutive patients undergoing liver surgery were treated according to this protocol (ERAS group). They were compared in terms of real in-hospital costs with a patient series before ERAS implementation (pre-ERAS group). Mean costs per patient were compared with a bootstrap T test. A cost-minimization analysis was performed.Results
Seventy-four ERAS patients were compared with 100 pre-ERAS patients. There were no significant pre- and intraoperative differences between the two groups, except for the laparoscopy number (n = 18 ERAS, n = 9 pre-ERAS, p = 0.010). Overall postoperative complications were observed in 36 (49 %) and 64 patients (64 %) in the ERAS and pre-ERAS groups, respectively (p = 0.046). The median length of stay was significantly shorter for the ERAS group (8 vs. 10 days, p = 0.006). The total mean costs per patient were €38,726 and €42,356 for ERAS and pre-ERAS (p = 0.467). The cost-minimization analysis showed a total mean cost reduction of €3080 per patient after ERAS implementation.Conclusions
ERAS implementation for liver surgery induced a non-significant decrease in cost compared to standard care. Significant decreased complication rate and hospital stay were observed in the ERAS group.17.
Steven M. Kurtz Edmund C. Lau Kevin L. Ong Edward M. Adler Frank R. Kolisek Michael T. Manley 《Clinical orthopaedics and related research》2017,475(12):2926-2937
Background
The Affordable Care Act of 2010 advanced the economic model of bundled payments for total joint arthroplasty (TJA), in which hospitals will be financially responsible for readmissions, typically at 90 days after surgery. However, little is known about the financial burden of readmissions and what patient, clinical, and hospital factors drive readmission costs.Questions/purposes
(1) What is the incidence, payer mix, and demographics of THA and TKA readmissions in the United States? (2) What patient, clinical, and hospital factors are associated with the cost of 30- and 90-day readmissions after primary THA and TKA? (3) Are there any differences in the economic burden of THA and TKA readmissions between payers? (4) What types of THA and TKA readmissions are most costly to the US hospital system?Methods
The recently developed Nationwide Readmissions Database from the Healthcare Cost and Utilization Project (2006 hospitals from 21 states) was used to identify 719,394 primary TJAs and 62,493 90-day readmissions in the first 9 months of 2013 based on International Classification of Diseases, 9th Revision, Clinical Modification codes. We classified the reasons for readmissions as either procedure- or medical-related. Cost-to-charge ratios supplied with the Nationwide Readmissions Database were used to compute the individual per-patient cost of 90-day readmissions as a continuous variable in separate general linear models for THA and TKA. Payer, patient, clinical, and hospital factors were treated as covariates. We estimated the national burden of readmissions by payer and by the reason for readmission.Results
The national rates of 30- and 90-day readmissions after THA were 4% (95% confidence interval [CI], 4.2%–4.5%) and 8% (95% CI, 7.5%–8.1%), respectively. The national rates of 30- and 90-day readmissions after primary TKA were 4% (95% CI, 3.8%–4.0%) and 7% (95% CI, 6.8%–7.2%), respectively. The five most important variables responsible for the cost of 90-day THA readmissions (in rank order, based on the Type III F-statistic, p < 0.001) were length of stay (LOS), all patient-refined diagnosis-related group (APR DRG) severity, type of readmission (that is, medical- versus procedure-related), hospital ownership, and age. Likewise, the five most important variables responsible for the cost of 90-day TKA readmissions were LOS, APR DRG severity, gender, hospital procedure volume, and hospital ownership. After adjusting for covariates, mean 90-day readmission costs reimbursed by private insurance were, on average, USD 1324 and USD 1372 greater than Medicare (p < 0.001) for THA and TKA, respectively. In the 90 days after TJA, two-thirds of the total annual readmission costs were covered by Medicare. In 90 days after THA, more readmissions were still associated with procedure-related complications, including infections, dislocations, and periprosthetic fractures, which in aggregate account for 59% (95% CI, 59.1%–59.6%) of the total readmission costs to the US healthcare system. For TKA, 49% of the total readmission cost (95% CI, 48.8%–49.6%) in 90 days for the United States was associated with procedure issues, most notably including infections.Conclusions
Hospital readmissions up to 90 days after TJA represent a massive economic burden on the US healthcare system. Approximately half of the total annual economic burden for readmissions in the United States is medical and unrelated to the joint replacement procedure and half is related to procedural complications.Clinical Relevance
This national study underscores LOS during readmission as a primary cost driver, suggesting that hospitals and doctors further optimize, to the extent possible, the clinical pathways for the hospitalization of readmitted patients. Because patients readmitted as a result of infection, dislocation, and periprosthetic fractures are the most costly types of readmissions, efforts to reduce the LOS for these types of readmissions will have the greatest impact on their economic burden. Additional clinical research is needed to determine the extent to which, if any, the LOS during readmissions can be reduced without sacrificing quality or access of care.18.
Jerry Yongqiang Chen Wu Chean Lee Hiok Yang Chan Paul Chee Cheng Chang Ngai Nung Lo Seng Jin Yeo 《International orthopaedics》2016,40(12):2505-2509
Purpose
In recent years, the exclusion of a drain in total knee arthroplasty (TKA) is gaining popularity. This retrospective study aims to investigate a tertiary hospital’s experience with the use of a drain in TKA. The authors hypothesise that the use of a drain will: (1) increase the peri-operative total blood loss (TBL) and transfusion rate; (2) increase the length of hospital stay (LOS); (3) reduce the 30-day readmission rate and incidence of additional surgical procedure performed.Methods
Patients who underwent a unilateral primary TKA in 2012 were included. Seven surgeons performed 575 TKAs with the use of drains, while nine other surgeons performed 902 TKAs without the use of drains. The patients were prospectively followed-up for two years. Peri-operative TBL was calculated using the haemoglobin balance method. All patients followed the hospital’s transfusion and post-operative rehabilitation protocol.Results
There was a bigger drop in haemoglobin level by 0.5 g/dl (95 % CI, 0.4, 0.6) and greater TBL by 169 ml (95 % CI, 126, 181) in the drain group (both p?<?0.001). However, the transfusion rate was 37/575 (6.4 %) and 48/902 (5.3 %) in the drain and no drain groups respectively (p?=?0.370), while the LOS was four (IQR, 4, 5) and four (IQR 3, 5) days respectively (p?=?0.228). The 30-day readmission rate was 10/575 (1.7 %) in the drain group, compared with 26/902 (2.9 %) in the no-drain group (p?=?0.165). The incidence of additional surgical procedure performed was 5/575 (0.9 %) in the drain group, compared with 15/902 (1.7 %) in the no-drain group (p?=?0.198).Conclusions
Although the use of a drain in TKA is associated with greater peri-operative TBL, this additional amount of blood loss does not translate into an increased transfusion rate or a longer LOS. It also does not reduce the 30-day readmission rate and incidence of additional surgical procedure performed on the same knee.19.
Purpose
Postoperative surgical complications arising from ventral hernia repair have been assessed by a variety of outcome measures. The objective of this study was to correlate the Clavien Dindo Classification (CDC) graded complications with the 30-day readmission rate as early outcome measures in ventral hernia repair. Secondarily, we wanted to investigate whether the risk factors for Clavien Dindo class ≥1 and 30-day readmission were comparable.Methods
Single-centre retrospective study including all patients (≥18 years) who underwent ventral hernia repair between January 1, 2009 and September 1, 2014 at Zealand University Hospital. Data were obtained from hospital files and the Danish National Patient Registry. A 100% follow-up was obtained.Results
In total, the study included 700 patients (261 patients with incisional hernia repair and 439 patients with umbilical or epigastric hernia repair). There was a significant association between a complication graded by the CDC ≥1 and 30-day readmission for both incisional and umbilical/epigastric hernia repair (p < 0.001). In incisional hernia, larger hernia size was an independent risk factor for CDC ≥1. No independent risk was found for 30-day readmission. Recurrent (vs. primary) hernia repair was an independent risk factors for both CDC ≥1 and 30-day readmission in umbilical/epigastric hernia repair. Furthermore, hernia size 2–7 cm (vs. >2 cm) was a risk factor for CDC ≥1 but not for 30-day readmission in umbilical/epigastric hernia repair.Conclusion
Reports on 30-day readmission can be used as a general outcome measure in ventral hernia repair, however CDC provides a more precise and detailed registration of postoperative complications.20.