Comparative outcomes of open versus laparoscopic sacrocolpopexy among medicare beneficiaries

Introduction and hypothesis

Since the first reported laparoscopic sacrocolpopexy in 1991, a limited number of single-center studies have attempted to assess the procedure’s effectiveness and safety. Therefore, we analyzed a national Medicare database to compare real-world short-term outcomes of open and laparoscopically assisted (including robotic) sacrocolpopexy in a United States sample of patients.

Methods

Public Use File data for a 5 % random national sample of all Medicare beneficiaries aged 65 and older were obtained from the Centers for Medicare and Medicaid Services for the years 2004–2008. Women with pelvic organ prolapse were identified using ICD-9 diagnosis codes. CPT-4 procedure codes were used to identify women who underwent open (code 57280) or laparoscopic (code 57425) sacrocolpopexy. Individual subjects were followed for 1 year post-operatively. Outcomes measured, using ICD-9 and CPT-4 codes, included medical and surgical complications and re-operation rates.

Results

Seven hundred and ninety-four women underwent open and 176 underwent laparoscopic (including robotic) sacrocolpopexy. Laparoscopic sacrocolpopexy was associated with a significantly increased rate of re-operation for anterior vaginal wall prolapse (3.4 % vs 1.0 %, p?=?0.018). However, more medical (primarily cardiopulmonary) complications occurred post-operatively in the open group (31.5 % vs 22.7 %, p?=?0.023). When sacrocolpopexy was performed with concomitant hysterectomy, mesh-related complications were significantly higher in the laparoscopic group (5.4 % vs 0 %, p?=?0.026).

Conclusion

Laparoscopic sacrocolpopexy resulted in an increased rate of reoperation for prolapse in the anterior compartment. When hysterectomy was performed at the time of sacrocolpopexy, the laparoscopic approach was associated with an increased risk of mesh-related complications.     

“Pathologic” fractures: should these be included in epidemiologic studies of osteoporotic fractures?

Summary

Pathologic fractures are often excluded in epidemiologic studies of osteoporosis. Using Medicare administrative data, we identified persons with vertebral and hip fractures. Among these, 48% (vertebral) and 3% (hip) of the fractures were coded as pathologic. Only 25% and 66% of persons with these pathologic fractures had evidence for malignancy.

Introduction

Analyses of osteoporosis-related fractures that use administrative data often exclude pathologic fractures (ICD-9 733.1x) due to concern that these are caused by cancer. We examined “pathologic” fractures of the vertebrae and hip to evaluate their contribution to fracture incidence and assessed the evidence for a malignancy.

Methods

We studied US Medicare beneficiaries age ≥65 with new fractures identified using ICD-9 diagnosis codes 733.13 (pathologic vert), 805.0, 805.2, 805.4, 805.8 (nonpathologic vert); and 733.14 (pathologic hip), 820.0, 820.2, 820.8 (nonpathologic hip). We further examined the proportion of cases with a diagnosis of a malignancy proximate to the fracture.

Results

We identified 44,120 individuals with a vertebral fracture and 60,354 with a hip fracture. Approximately 48% of vertebral fractures and 3% of hip fractures were coded as pathologic. For only approximately 25% of persons with a “pathologic” vertebral fracture ICD-9 code, but 66% of persons with a “pathologic” hip fracture, there was evidence of a possible cancer diagnosis.

Conclusion

Among US Medicare beneficiaries, one fourth of pathologic vertebral fracture and two thirds of pathologic hip fracture cases had evidence for a malignancy. Particularly for vertebral fractures, excluding persons with pathologic fractures in epidemiologic analyses that utilize administrative claims data substantially underestimates the burden of fractures due to osteoporosis.     

Impact of Availability of Immediate Breast Reconstruction on Bilateral Mastectomy Rates for Breast Cancer across the United States: Data from the Nationwide Inpatient Sample

Background

Availability of immediate breast reconstruction (IBR) varies among institutions, yet the impact of IBR availability on the rates of bilateral mastectomy (BM) versus unilateral mastectomy (UM) for breast cancer is unknown.

Methods

From the 2002 to 2010 Nationwide Inpatient Sample, we identified women with breast cancer undergoing UM or BM with and without IBR using ICD-9 codes. Hospitals were classified as performing IBR if at least one hospitalization included both mastectomy and reconstruction and then by IBR volume. Statistical comparisons utilized Chi square tests, tests for trend, and multivariable logistic regression.

Results

We identified 130,420 women undergoing UM (76.9 %) or BM (23.1 %) for breast cancer. Of 6,579 hospitals, 3,358 (51.0 %) performed no IBRs, while in the remaining 3,221 hospitals, 1 to 638 IBRs were performed per year. Large, teaching, urban, and Northeastern hospitals were more likely to have higher IBR volumes. BM rates were significantly higher in patients treated at those hospitals with higher IBR volumes, from 33.1 % at hospitals performing ≥24 IBRs per year to 9.0 % at hospitals without IBR (p < 0.001). Upon adjusted analysis, patients who elected BM were more likely to be seen at hospitals performing ≥24 IBRs per year (odds ratio 1.69 vs. UM, p < 0.001).

Conclusions

In this analysis of national data, BM rates were higher in hospitals where IBR was available, suggesting a significant influence of institutional factors on treatment options for breast cancer patients. Efforts are needed to ensure patients have access to IBR when desired and to better understand the reasons for hospital variation in BM rates.     

Utilization of Mastectomy and Reconstruction in the Outpatient Setting

Background

Reconstruction rates after mastectomy have been reported to range from 25–40 %; however, most studies have focused on patients treated in an inpatient setting. We sought to determine the utilization of outpatient mastectomy and use of breast reconstruction in Southern California.

Methods

Postmastectomy reconstruction rates were determined from the California Office of Statewide Health Planning and Development database from 2006–2009 using CPT codes and similarly from an inpatient database using ICD-9 codes. Reconstruction rates were compared between the inpatient and outpatient setting. For the outpatient setting, univariate and multivariate odds ratios with 95 % confidence intervals were estimated for relative odds of immediate reconstruction versus mastectomy alone.

Results

The percentage of patients undergoing outpatient mastectomy ranged from 20.4 to 23.9 % of the total number of all patients undergoing mastectomy. Whereas immediate inpatient reconstruction increased from 29.2 to 41.6 % (overall rate 35.5 %), the proportion of outpatients undergoing reconstruction only increased from 7.7 to 10.3 % (overall rate 9.1 %). Similar to the inpatient setting, in multivariate analysis, age, insurance status, race/ethnicity, and type of hospital were significantly associated with the use of reconstruction in the outpatient setting.

Conclusions

A substantial number of patients undergo outpatient mastectomy with low rates of reconstruction. Although the choice of an outpatient mastectomy may certainly represent a selection bias for those not choosing reconstruction, an increase in the use of outpatient mastectomy may result in decreases in the use of postmastectomy reconstruction.     

Incidence of postoperative delirium is high even in a population without known risk factors

Purpose

Postoperative delirium is a recognized complication in populations at risk. The aim of this study is to assess the prevalence of early postoperative delirium in a population without known risk factors admitted to the ICU for postoperative monitoring after elective major surgery. The secondary outcome investigated is to identify eventual independent risk factors among demographic data and anesthetic drugs used.

Methods

An observational, prospective study was conducted on a consecutive cohort of patients admitted to our ICU within and for at least 24 h after major surgical procedures. Exclusion criteria were any preexisting predisposing factor for delirium or other potentially confounding neurological dysfunctions. Patients were assessed daily using the confusion assessment method for the ICU scale for 3 days after the surgical procedure. Early postoperative delirium incidence risk factors were then assessed through three different multiple regression models.

Results

According to the confusion assessment method for the ICU scale, 28 % of patients were diagnosed with early postoperative delirium. The use of thiopentone was significantly associated with an eight-fold-higher risk for delirium compared to propofol (57.1 % vs. 7.1 %, RR = 8.0, χ ² = 4.256; df = 1; 0.05 < p < 0.02).

Conclusion

In this study early postoperative delirium was found to be a very common complication after major surgery, even in a population without known risk factors. Thiopentone was independently associated with an increase in its relative risk.     

Haloperidol prophylaxis does not prevent postoperative delirium in elderly patients: a randomized,open-label prospective trial

Purpose

Postoperative delirium is the most common postoperative complication in the elderly. The purpose of this study was to evaluate the safety and effectiveness of the preventive administration of low-dose haloperidol on the development of postoperative delirium after abdominal or orthopedic surgery in elderly patients.

Subjects

A total of 119 patients aged 75 years or older who underwent elective surgery for digestive or orthopedic disease were included in this study.

Methods

Patients were divided into those who did (intervention group, n = 59) and did not (control group, n = 60) receive 2.5 mg of haloperidol at 18:00 daily for 3 days after surgery; a randomized, open-label prospective study was performed on these groups. The primary endpoint was the incidence of postoperative delirium during the first 7 days after the operation.

Results

The incidence of postoperative delirium in all patients was 37.8 %. No side effects involving haloperidol were noted; however, the incidences of postoperative delirium were 42.4 and 33.3 % in the intervention and control groups, respectively, which were not significantly different (p = 0.309). No significant effect of the treatment was observed on the severity or persistence of postoperative delirium.

Conclusions

The preventive administration of low-dose haloperidol did not induce any adverse events, but also did not significantly decrease the incidence or severity of postoperative delirium or shorten its persistence.     

A prospective cohort study evaluating associations among delirium, postoperative cognitive dysfunction, and apolipoprotein E genotype following open aortic repair

Background

Patients undergoing major vascular surgery are at high risk of postoperative delirium and postoperative cognitive dysfunction (POCD). Apolipoprotein E (APOE) is involved in central acetylcholine synthesis, and patients bearing the ε4 genotype (APOE-ε4) are at increased risk of both vascular dementia and peripheral vascular disease. The purpose of this study was to evaluate the associations among delirium, POCD, and APOE-ε4 in patients undergoing open aortic repair.

Methods

Following Research Ethics Board approval and written informed consent, we recruited a cohort of patients ≥ 60 yr of age undergoing open aortic repair. Apolipoprotein E genotyping and a battery of nine neuropsychometric (NP) tests were performed prior to surgery. Delirium was assessed on postoperative days two, four, and discharge using the Confusion Assessment Method. Neuropsychometric testing was repeated at discharge and again three months following surgery. A group of non-surgical patients was used to adjust NP scores using reliable change index methodology. Logistic regression was used to evaluate independent predictors of both delirium and POCD.

Results

Eighty-eight patients underwent surgery, 78 completed NP testing on discharge, and sixty-nine completed NP testing at three months. Delirium was noted in 36% of patients after surgery, while POCD was noted in 62% at discharge and 6% at three months. Delirium predicted POCD at discharge (odds ratio 2.86; 95% confidence intervals 0.99 to 8.27) but not at three months. Apolipoprotein E-ε4 genotype was not associated with either delirium or POCD following adjustment for covariates.

Conclusion

Both delirium and POCD are common following open aortic repair; however, the APOE genotype did not predict either condition. This trial has been registered with ClinicalTrials.gov (NCT00911677).     

Nationwide practice patterns for the use of venous thromboembolism prophylaxis among men undergoing radical prostatectomy

Purpose

To examine the practice patterns and predictors of VTE prophylaxis following radical prostatectomy (RP).

Methods

This was a population-based observational study of 94,709 men with a diagnosis of prostate cancer (ICD-9 code 185) who underwent RP were identified from a hospital-based database from 2000 to 2010, including 68,244 (72.1 %) open RP (ORP) and 26,465 (27.9 %) robotic-assisted laparoscopic RP (RALP). VTE prophylaxis was classified as none, mechanical, pharmacologic, or combination.

Results

Following RP, 35,591 (52.2 %) received mechanical, 4,945 (7.2 %) pharmacologic, 7,720 (10.6 %) combination, and 20,438 (30.0 %) no VTE prophylaxis. A total of 245 VTE events (145 DVT, 114 PE) were identified, representing 0.25 % of all procedures. Men with >2 comorbidities (OR = 2.44; 95 % CI 1.78–3.35) and those who were black (OR = 1.44; 95 % CI 1.06–1.97) were more likely to have a VTE. Men who had RALP (OR = 0.61; 95 % CI 0.45–0.99), surgery at high-volume hospitals (OR = 0.45; 95 % CI 0.28–0.73), or received prophylaxis (OR = 0.67; 95 % CI 0.50–0.88) were less likely to develop a VTE.

Conclusion

Despite the observation that VTE prophylaxis reduces the risk of VTE by 40 %, VTE prophylaxis was not used in almost one-third of men who underwent radical prostatectomy.     

Disparities in osteoporosis treatments

Summary

Osteoporosis treatment rates within 2 years following an index event (fragility fracture, osteoporotic bone mineral density (BMD) T-score, or osteoporosis ICD-9 codes) were determined from 2005 to 2011. Most patients were not treated. Fracture patients had the lowest treatment rate. Low treatment rates also occurred in patients that were male, black, or had non-commercial insurance.

Introduction

Clinical recognition of osteoporosis (osteoporotic BMD, assignment of an ICD-9 code, or the occurrence of fragility fractures) provides opportunities to treat patients at risk for future fracture.

Methods

A cohort of 36,965 patients was identified from 2005 to 2011 in the Indiana Health Information Exchange, with index events after age 50 of either non-traumatic fractures, an osteoporosis ICD-9 code, or a BMD T-score?≤??2.5. Patients with osteoporosis treatment in the preceding year were excluded. Medication records during the ensuing 2 years were extracted to identify osteoporosis treatments, demographics, comorbidities, and co-medications. Predictors of treatment were evaluated in a multivariable logistic regression model.

Results

The cohort was 78 % female, 11 % black, 91 % urban-dwelling, and 53 % commercially insured. The index events were as follows: osteoporosis diagnosis (47 % of patients), fragility fracture (44 %), and osteoporotic T-scores (9 %). Within 2 years after the index event, 23.3 % received osteoporosis medications (of which, 82.2 % were oral bisphosphonates). Treatment rates were higher after osteoporosis diagnosis codes (29.3 %) or osteoporotic T-score (53.9 %) than after fracture index events (10.5 %) (p?<?0.001). Age had an inverted U-shaped effect for women with highest odds around 60–65 years. Women (OR 1.86) and non-black patients (OR 1.52) were more likely to be treated (p?<?0.001). Patients with public (versus commercial) insurance (OR 0.86, p?<?0.001) or chronic comorbidities (ORs about 0.7–0.9, p?<?0.001) were less likely to be treated.

Conclusion

Most osteoporosis treatment candidates remained untreated. Men, black patients, and patients with fracture or chronic comorbidities were less likely to receive treatment, representing disparity in the recognition and treatment of osteoporosis.

     

Acetabular retroversion in post slipped capital femoral epiphysis deformity

Purpose

While the femoral deformity in post slipped capital femoral epiphysis (SCFE) hips has been implicated in the development of femoral acetabular impingement, little has been studied about the acetabular side. The purpose of our study was to determine the frequency of morphologic changes suggestive of acetabular retroversion in patients who have sustained a SCFE.

Methods

IRB approval was obtained and the records of patients from 1975 to 2010 were searched for ICD-9 codes for SCFE. A total of 188 patients were identified for the study. Two observers evaluated AP radiographs for evidence of acetabular retroversion as characterized by the presence of either an ischial spine sign or a crossover sign. Demographic data, date of onset, and treatment were recorded. For analysis, the right hip was used in patients with bilateral involvement.

Results

Of the 188 patients identified, 5 patients had an incorrect diagnosis and 41 patients had missing or inadequate films, leaving 142 patients (284 hips) for review. 57 patients (114 hips) had bilateral SCFE and 85 patients had unilateral SCFE. 79 % (n = 45) of the right hips with bilateral SCFE and 82 % (n = 70) of the unilateral involved hips had at least one sign of retroversion. Uninvolved hips had at least one sign of retroversion 76 % (n = 65) of the time.

Conclusions

When compared to previously published values for normal patients, patients with SCFE appear to have an increased incidence of acetabular retroversion.     

Bariatric Surgery Is Acceptably Safe in Obese Inflammatory Bowel Disease Patients: Analysis of the Nationwide Inpatient Sample

Background

The prevalence of obesity in patients with inflammatory bowel disease (IBD) has increased over the past decades. Data to support the safety of bariatric surgery (BAR) in IBD remain scarce. Our aim was to evaluate the safety and early postoperative complications of BAR in IBD patients.

Methods

We used the Nationwide Inpatient Sample (NIS) 2011, 2012, and 2013 to perform a cohort study. The study group was all hospitalized patients between ages 18–90 years who underwent BAR with a discharge diagnosis of IBD as per the Ninth International Classification of Diseases codes (ICD-9). Adults who underwent BAR without ICD-9 codes of IBD were identified as the comparison group. Complications were compared using multivariate logistic regression analysis.

Results

We identified 314,864 adult patients who underwent BAR between 2011 and 2013. Mean age was 45.5 ± 0.11 years, and 79% were females. Seven hundred and ninety patients had underlying IBD; 459 had Crohn’s disease and 331 had ulcerative colitis. The remaining patients formed the comparison group. Mean length of hospital stay (LOS) was longer in the IBD group by 1 day (p = 0.01). The IBD group had a significantly higher risk of perioperative small bowel obstruction (SBO) (adjusted odds ratio, 4.0; 95%, CI; 2.2–7.4). Other technical and systemic complications were similar between the two groups, with no mortality reported in the IBD group.

Conclusions

BAR in IBD patients has an acceptable safety profile, with immeditae risk limited to perioperative SBO and an apparently low risk of mortality or other major immediate postoperative complications.

     

Beyond the learning curve: incidence of bile duct injuries following laparoscopic cholecystectomy normalize to open in the modern era

Background

Early reports of higher complication rates, specifically bile duct injuries, raised concerns over the safety of laparoscopy over open cholecystectomy. This study aims to ascertain the rate, management, and perioperative outcomes of bile duct injury in an era beyond the laparoscopic learning curve.

Methods

The New York State (NYS) Planning and Research Cooperative System longitudinal administrative database was used to identify patients. From 2005 to 2010, 156,315 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Patients were then tracked with unique identifiers for common bile duct injury. Common bile duct injury was identified by ICD-9 and CPT diagnosis and procedure codes for patients who subsequently underwent hepatectomy, hepaticojejunostomy, or other bile duct surgery.

Results

From 2005 to 2010, 156,958 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Of the total patients, 149 patients underwent a biliary duct procedure within a year. Twenty-four of them were diagnosed with gallbladder cancer and excluded, leaving 125 for further analysis. The biliary injuries were identified at a rate of 0.080 %. Thirty-one of those patients (24.8 %) underwent hepatectomy, 40 patients (32.0 %) underwent hepaticoenterostomy, and 54 patients (43.2 %) underwent primary repair of the bile duct. Thirty-two (26 %) patients were repaired on the same day of their initial procedure. Of the remaining 93 patients, 38 (30 %) were repaired within 10 days, seven (6 %) repaired between 11 and 20 days, and 48 (38 %) patients over 21 days from injury.

Conclusion

In NYS, the rate of bile duct injury has now decreased to 0.08 % and mirrors the historical figures quoted for open cholecystectomy. This improvement likely reflects increased experience, improved instrumentation, and movement beyond the “learning curve.”

     

Incidental dural tear in spine surgery: analysis of a nationwide database

Purpose

The purpose of this study was to report the incidence of dural tear (DT) in spine surgery, risk factors, and patient outcomes on a national level.

Methods

Clinical data were obtained from the Nationwide Inpatient Sample for 2009. Patients who underwent spine surgery were identified and, among them, patients who had DT were identified, according to the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes. Patient and hospital demographic data were retrieved. The incidence of DT and in-hospital patient outcomes were analyzed. Multivariate logistic regression analysis was performed to identify the risk factors for DT.

Results

The incidence of DT was 2.7 % (17,932/665,818). Multivariate analysis revealed that older age, female gender, increased Elixhauser comorbidity score, and high hospital caseload were the significant risk factors for DT. Comparison between patients with and without DT showed that those with DT had significantly higher overall in-hospital complications (18.8 vs. 10.2 %), higher in-hospital mortality rate (0.4 vs. 0.3 %), longer hospital stays (5.1 vs. 3.7 days), lower proportion discharged home routinely (61.0 vs. 76.8 %), and increased total hospital charges ($85,138 vs. $71,808), respectively.

Conclusions

The reported incidence of DT in spine surgery was 2.7 % in the US. Risk factors included older age, female gender, increased comorbidities, and high hospital caseload. DT increased the rate of in-hospital complications and mortality and health care burdens.     

A population-based analysis of emergent versus elective paraesophageal hernia repair using the Nationwide Inpatient Sample

Background

As the life expectancy in the United States continues to increase, more elderly, sometimes frail patients present with sub-acute surgical conditions such as a symptomatic paraesophageal hernia (PEH). While the outcomes of PEH repair have improved largely due to the proliferation of laparoscopic surgery, there is still a defined rate of morbidity and mortality. We sought to characterize the outcomes of both elective and emergent PEH repair using a large population-based data set.

Methods

The Nationwide Inpatient Sample was queried for primary ICD-9 codes associated with PEH repair (years 2006–2008). Outcomes were in-hospital mortality and the occurrence of a pre-identified complication. Multivariate analysis was performed to determine the risk factors for complications and mortality following both elective and emergent PEH repair.

Results

A total of 8,462 records in the data, representing 41,723 patients in the US undergoing PEH repair in the study interval, were identified. Of these procedures, 74.2 % was elective and 42.4 % was laparoscopic. The overall complication and mortality rates were 20.8 and 1.1 %, respectively. Emergent repair was associated with a higher rate of morbidity (33.4 vs. 16.5 %, p < 0.001) and mortality (3.2 vs. 0.37 %, p < 0.001) than elective repair. Emergent repair patients were more likely to be male, were older, and more likely to be minority. Logistic modeling revealed that younger age, elective case status, and a laparoscopic approach were independently associated with a lower probability of complications and mortality.

Conclusions

Patients undergoing emergent PEH repair in the United States tend to be older, more likely a racial minority, and less likely to undergo laparoscopic repair. Elective repair, younger age, and a laparoscopic approach are associated with improved outcomes. Considering all of the above, we recommend that patients consider elective repair with a surgeon experienced in the laparoscopic approach, especially when symptoms related to the hernia are present.     

National disparities in laparoscopic colorectal procedures for colon cancer

Introduction

Racial disparity in the treatment of colorectal cancer (CRC) has been cited as a potential cause for differences in mortality. This study compares the rates of laparoscopy according to race, insurance status, geographic location, and hospital size.

Methods

The 2009 Healthcare Cost and Utilization Project: Nationwide Inpatient Sample (HCUP-NIS) database was queried to identify patients with the diagnosis of CRC by the International Classification of Diseases, Ninth Revision (ICD-9) codes. Multivariate logistic regression was performed to look at age, gender, insurance coverage, academic versus nonacademic affiliated institutions, rural versus urban settings, location, and proportional differences in laparoscopic procedures according to race.

Results

A total of 14,502 patients were identified; 4,691 (32.35 %) underwent laparoscopic colorectal procedures and 9,811 (67.65 %) underwent open procedures. The proportion of laparoscopic procedures did not differ significantly by race: Caucasian 32.4 %, African-American 30.04 %, Hispanic 33.99 %, and Asian-Pacific Islander 35.12 (P = 0.08). Among Caucasian and African-American patients, those covered by private insurers were more likely to undergo laparoscopic procedures compared to other insurance types (P ≤ 0.001). The odds of receiving laparoscopic procedure at teaching hospitals was 1.39 times greater than in nonteaching hospitals (95 % confidence interval [CI] 1.29–1.48) and did not differ across race groups. Patients in urban hospitals demonstrated higher odds of laparoscopic surgery (2.24, 95 % CI 1.96–2.56) than in rural hospitals; this relationship was consistent within races. The odds of undergoing laparoscopic surgeries was lowest in the Midwest region (0.89, 95 % CI 0.81–0.97) but higher in the Southern region (1.14, 95 % CI 1.06–1.22) compared with the other regions.

Conclusions

Nearly one-third of all CRC surgeries are laparoscopic. Race does not appear to play a significant role in the selection of a laparoscopic CRC operation. However, there are significant differences in the selection of laparoscopy for CRC patients based on insurance status, geographic location, and hospital type.     

Electronic medical record: research tool for pancreatic cancer?

Background

A novel data warehouse based on automated retrieval from an institutional health care information system (HIS) was made available to be compared with a traditional prospectively maintained surgical database.

Methods

A newly established institutional data warehouse at a single-institution academic medical center autopopulated by HIS was queried for International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes for pancreatic neoplasm. Patients with ICD-9-CM diagnosis codes for pancreatic neoplasm were captured. A parallel query was performed using a prospective database populated by manual entry. Duplicated patients and those unique to either data set were identified. All patients were manually reviewed to determine the accuracy of diagnosis.

Results

A total of 1107 patients were identified from the HIS-linked data set with pancreatic neoplasm from 1999–2009. Of these, 254 (22.9%) patients were also captured by the surgical database, whereas 853 (77.1%) patients were only in the HIS-linked data set. Manual review of the HIS-only group demonstrated that 45.0% of patients were without identifiable pancreatic pathology, suggesting erroneous capture, whereas 36.3% of patients were consistent with pancreatic neoplasm and 18.7% with other pancreatic pathology. Of the 394 patients identified by the surgical database, 254 (64.5%) patients were captured by HIS, whereas 140 (35.5%) patients were not. Manual review of patients only captured by the surgical database demonstrated 85.9% with pancreatic neoplasm and 14.1% with other pancreatic pathology. Finally, review of the 254 patient overlap demonstrated that 80.3% of patients had pancreatic neoplasm and 19.7% had other pancreatic pathology.

Conclusions

These results suggest that cautious interpretation of administrative data rely only on ICD-9-CM diagnosis codes and clinical correlation through previously validated mechanisms.     

The clock drawing test is a poor screening tool for postoperative delirium and cognitive dysfunction after aortic repair

Background

The Clock Drawing Test (CDT) is a screening tool for dementia that tests a variety of cognitive domains. The CDT takes a maximum of two minutes to complete and might be helpful in identifying postoperative cognitive disorders at the bedside. The objective of this study was to evaluate the accuracy of the CDT in a population at high risk for postoperative cognitive disorders

Methods

In this prospective observational cohort study, patients were recruited who were ≥ 60 yr of age and scheduled for elective open repair of the abdominal aorta. Delirium was assessed using the Confusion Assessment Method (CAM) on postoperative days (POD) 2 and 4 and at discharge. Cognitive function was assessed with neuropsychometric tests before surgery and at discharge. Postoperative cognitive dysfunction (POCD) was determined using the Reliable Change Index. Clock Drawing Tests were administered at all time points. Agreement between the CDT and test for delirium or POCD was assessed with Cohen’s Kappa statistic.

Results

Delirium was noted in 30 of 83 patients (36%; 95% confidence interval [CI] 26 to 46%) during their hospital stay, while POCD was noted in 48 of 78 patients (60%; 95% CI 51 to 72%) at discharge. Agreement between the CDT and CAM was poor at three intervals (Kappa 0.06 to 0.29), as was POCD at discharge (Kappa 0.46). Sensitivity of the CDT was <0.71 for both delirium and POCD at all intervals. False positives and negatives were common.

Conclusion

Agreement between CDT and tests for delirium and POCD was poor; sensitivity was inadequate for a screening test. (ClinicalTrials.gov number, NCT00911677).     

Four-year trends in the treatment of cerebral aneurysms in Poland in 2009-2012

Background

The dilemma concerning the appropriate treatment of the intracranial aneurysms (IAs) has not yet been resolved and still remains under fierce debate. This study refers to the recent trends in the use of and outcomes related to coiling compared with clipping for unruptured and ruptured IAs in Poland over a 4-year period.

Methods

The analysis refers to treatment of IAs performed in Poland between 2009-2012. Patients’ records were cross-matched by ICD-9 codes for ruptured SAH (430) or unruptured cerebral aneurysm (437.3) along with codes for clipping (39.51) and coiling (39.79, 39.72, or 39.52). Multivariable logistic regression was used to compare in-hospital deaths, hospital length of stay (LOS), therapy allocation and aneurysm locations in unruptured vs. ruptured and clipped vs. coiled groups. Differences in the number of procedures between 16 administrative regions were standardized per 100,000 people.

Results

In 2009-2012, 11,051 procedures were identified, including 5,968 ruptured and 5,083 unruptured aneurysms. Overall increase was 2.3 % in clipping and 13.1 % in coiling; a significant trend was found in endovascular procedures (p?=?0.044). Ruptured aneurysms were clipped more frequently (OR?=?1.66;); in unruptured IAs, endovascular procedure was preferred 3.5 times more than clipping. The annual in-hospital mortality was 7.6 % in clipping and 6.7 % in endovascular treatment. LOS was two times longer after clipping in unruptured aneurysms (OR?=?2.013). After the procedures were standardized per 100,000 people, the average for Poland was established as 9.09 in 2009, 10.86 in 2010, 10.55 in 2011, and 11.49 in 2012. This index had the highest values in Mazovia (12.9, 2009; 15.4, 2010; 17.4, 2011; 18.6, 2012.

Conclusions

Data analysis revealed an increase in overall number of IAs treated in Poland between 2009-2012. A significant upward trend of endovascular procedures was found, whereas the number of clipped aneurysms remained relatively steady over the study period.     

Incidence and Risk Factors of Postoperative Delirium in Patients with Esophageal Cancer

Background

Postoperative delirium is a common complication after major surgery and is characterized by acute confusion with fluctuating consciousness. The aim of this study was to investigate the incidence and risk factors of postoperative delirium in patients with esophageal cancer.

Methods

We conducted a retrospective cohort analysis of 306 consecutive patients who had undergone an esophagectomy at Keio University Hospital from January 1998 to December 2009. All data were assessed by psychiatrists, and delirium was diagnosed according to criteria of the Diagnostic and Statistical Manual Disorder, fourth edition. Univariate and multivariate analyses were performed.

Results

Postoperative delirium developed in 153 (50.0?%) of 306 patients. One hundred fourteen (37.3?%) of the 306 patients required psychoactive medication for symptoms associated with delirium. Univariate analyses showed that older age, male gender, additional flunitrazepam for sedation in intensive care unit (ICU) after surgery, longer periods of time under mechanical ventilation after surgery, longer ICU stays, occurrence of postoperative complications, and longer hospital stays were significantly associated with postoperative delirium. Multivariate analysis revealed that development of delirium was linked to older age, additional flunitrazepam in ICU, and occurrence of postoperative complication.

Conclusions

The development of postoperative delirium in patients with esophageal cancer is a problem that cannot be ignored. Our results suggest that the risk of developing delirium is associated with older age, use of flunitrazepam in ICU, and postoperative complications.