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Background: Reducing inpatient readmissions is a national priority for improving healthcare quality and decreasing costs. Previous studies have shown that readmissions after surgical aortic valve replacement are frequent and contribute to increased healthcare costs, yet no studies have analyzed risk factors for readmission., Methods: The Nationwide Readmissions Database was used to identify adult patients undergoing surgical aortic valve replacement from 2010 to 2015. Incidence, patient characteristics, causes, resource utilization, and predictors of 30-day readmission were determined. International Classification of Diseases codes were used to capture surgical aortic valve replacement., Results: Among 136,051 patients, 18,631 (13.7%) were readmitted within 30 days of discharge. Readmitted patients were more commonly women (47.4% vs 41.6%; P < .001) and were older (70.4 years of age vs 68.3 years of age; P < .001), with higher Elixhauser comorbidity index (5.4 vs 4.8; P < .001), rates of postoperative complications (44.0% vs 37.3%; P < .001), and greater length of stay (10.9 days vs 8.5 days; P < .001). The mean cost of 1 readmission episode was $13,426. On multivariable analysis, significant predictors of readmission were female sex, age greater than 75 years, atrial fibrillation, chronic kidney and liver disease, and lower surgical aortic valve replacement hospital volume. A total of 49.1% of readmissions were related to cardiac causes, with heart failure (13.2%) and arrhythmia (12.5%) being the most common., Conclusions: Using a national inpatient database, we found readmission after surgical aortic valve replacement to be common and resource-intensive. Enhanced management of comorbidities and targeted postdischarge interventions for patients at high risk of readmission may help decrease healthcare utilization., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Deep venous thrombosis and pulmonary embolism are life-threatening complications after surgery, warranting prophylaxis. However prophylaxis is not uniformly practiced among cardiac surgical patients. This study aimed to characterize the national incidence, mortality, and costs associated with thromboembolism after cardiac surgery., Methods: The 2005 to 2015 National Inpatient Sample was used to identify all adult patients undergoing coronary artery bypass grafting or valve surgery. International Classification of Disease codes were used to identify patients with deep venous thrombosis and pulmonary embolism., Results: Of approximately 3 million patients undergoing cardiac surgery, 1.62% developed deep venous thrombosis and 0.38% pulmonary embolism. Those with deep venous thrombosis and pulmonary embolism were more commonly women (33.2% and 36.2 vs 31.2%, P < .001), older (68.1 and 66.0% vs 65.7 years, P < .001), and had a higher Elixhauser comorbidity index (4.0 and 4.7 vs 3.7, P < .001). Deep venous thrombosis and pulmonary embolism were associated with increased mortality (4.95% and 14.8% vs 2.67%, P < .001). After adjustment for baseline differences, deep venous thrombosis was associated with an incremental increase in cost of $12,308, whereas pulmonary embolism was associated with $13,879 cost increase after cardiac surgery. Pulmonary embolism was an independent predictor of mortality (adjusted odds ratio, 3.39; 95% confidence interval, 2.74-4.18)., Conclusions: The mortality and financial burden related to thromboembolism in cardiac surgery are significant. Prophylaxis may be indicated in cardiac surgery patients to improve quality of care and reduce healthcare costs. Future controlled randomized trials investigating the benefit of thromboembolism prophylaxis in cardiac surgery are warranted., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Malnutrition is associated with increased mortality in open cardiac surgery, but its impact on transcatheter aortic valve implantation (TAVI) is unknown. This study utilized the National Readmissions Database to evaluate the impact of malnutrition on mortality, complications, length of stay (LOS), 30-day readmission, and total charges following TAVI. Adult patients undergoing isolated TAVI for severe aortic stenosis were identified using the 2011 to 2016 National Readmissions Database, which accounts for 56.6% of all US hospitalizations. The malnourished cohort included patients with nutritional neglect, cachexia, protein calorie malnutrition, postsurgical nonabsorption, weight loss, and underweight status. Multivariable models were utilized to evaluate the impact of malnutrition on selected outcomes. Of 105,603 patients, 5,280 (5%) were malnourished. Malnourished patients experienced greater mortality (10.4% vs 2.2%, p <0.001), postoperative complications (49.2% vs 22.6%, p <0.001), 30-day readmission rates (21.4 vs 14.9%, p <0.001), index hospitalization charges ($331,637 vs $208,082, p <0.001), and LOS (16.4 vs 6.2 days, p <0.001) relative to their nourished counterparts. On multivariable analysis, malnutrition remained a significant, independent predictor of increased index mortality (Adjusted odds ratio (AOR) = 2.68, p <0.001), complications (AOR = 2.09, p <0.001), and 30-day readmission rates (AOR = 1.34, p <0.001). Malnutrition was most significantly associated with infectious complications at index hospitalization (AOR = 3.88, p <0.001) and at 30-day readmission (AOR = 1.43, p <0.027). In conclusion, malnutrition is independently associated with increased mortality, complications, readmission, and resource utilization in patients undergoing TAVI. Preoperative risk stratification and malnutrition modification may improve outcomes in this vulnerable population., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Readmissions after colorectal operations adversely impact patient recovery and are associated with about $300 million in additional health care expenditure in the United States alone. The present study aimed to characterize nonelective, short-term readmissions of colorectal surgery patients who underwent colostomy., Methods: The Nationwide Readmissions Database was used to identify patients who received a colostomy from 2010 to 2015. Patients were stratified by discharge-to-readmission interval: immediate (within 7 d) and delayed (7-30 d). Nonparametric trend analysis and multivariable regression were performed to identify predictors of immediate and delayed readmission., Results: Of an estimated 376,693 operations requiring colostomies during the study, in-hospital survival was 92.3%, with higher rates after elective compared with nonelective operations (96.5 versus 90.8%, P < 0.001). Overall, 15.3% patients undergoing elective and nonelective colostomy creation returned to the hospital within 30 d, with 41.6% of these readmissions occurring by the first week of discharge (immediate). Readmission rates and proportion of immediate and delayed groups did not significantly change over the 6-year study period. Nonhome discharge increased the odds of immediate (AOR 1.25, 95% CI 1.17-1.34) and delayed readmission (AOR 1.44, 95% CI 1.35-1.54). Annually, immediate and delayed rehospitalizations after colostomy creation were responsible for $64 and 82 million in excess costs, respectively., Conclusions: Colostomy creation is associated with a steady and high rate of rehospitalization. Nonhome discharge, in addition to several patient comorbidities, is associated with higher odds of readmission. Programs aimed at reduction of immediate readmission are warranted., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: The incidence of severe perioperative renal dysfunction in high-acuity patients has not been well-explored at the national level. The present study aimed to evaluate the trends in the incidence of perioperative acute kidney injury and renal replacement therapy as well as associated mortality among patients undergoing an emergency general surgery operation., Methods: This was a retrospective cohort study using the National Inpatient Sample to identify all adult patients (>18 y) without chronic kidney disease who underwent an emergency general surgery procedure from 2008 to 2016. The study cohort was stratified based on presence of acute kidney injury and need for renal replacement therapy postoperatively. A multivariable logistic regression model was developed to predict the odds of mortality and composite morbidity. Nonparametric trend analyses of acute kidney injury and renal replacement therapy incidence and associated mortality were performed., Results: Of an estimated 5,862,657 patients who underwent an emergency general surgery procedure during the study period, 7.4% patients developed an acute kidney injury and 0.48% patients required renal replacement therapy. Overall, the incidence of acute kidney injury (5.3%-19.4%) and renal replacement therapy (0.43%-0.93%) increased (P < .0001) over the study period. Even without need for renal replacement therapy, acute kidney injury was associated with greater odds of mortality and composite morbidity (adjusted odds ratio 5.2, 95% confidence interval [CI] 5.1-5.3) and mortality (adjusted odds ratio = 2.20, 95% CI 2.3-2.4), as well as greater costs of hospitalization and duration of stay., Conclusion: In this national study, we found that the incidence of acute kidney injury and renal replacement therapy after an emergency general surgery operation has increased. Both acute renal failure and hemodialysis were associated with much greater odds of morbidity and mortality. The apparent increase in the rate of acute kidney injury and renal replacement therapy warrant further investigation of mechanisms for monitoring and limiting the impact of organ malperfusion associated with emergency general surgery operations., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Hospitals with safety-net status have been associated with inferior surgical outcomes and higher costs. The mechanism of this discrepancy, however, is not well understood. We hypothesized that discrepant rates of failure to rescue after complications of routine cardiac surgery would explain the observed inferior outcomes at safety-net hospitals., Methods: The National Inpatient Sample was used to identify adult patients who underwent elective coronary artery bypass grafting and isolated or concomitant valve operations between January 2005 and December 2016. Hospitals were stratified into low-, medium-, or high-burden categories based on the proportion of uninsured or Medicaid patients to emulate safety-net status as defined by the Institute of Medicine. Failure to rescue was defined as mortality after occurrence of neurologic, cardiovascular, respiratory, renal, or infectious complications (major and minor complications). Multivariable regression was used to perform risk-adjusted comparisons of the rate of complications, failures to rescue, and resource use for high-burden hospitals versus low-burden and medium-burden hospitals., Results: Of an estimated 2,012,104 patients undergoing elective major cardiac operations, 2% died, whereas 36% suffered major and minor complications. Safety-net hospitals had higher odds of failure to rescue after major comorbidity (adjusted odds ratio 1.12, 95% confidence interval 1.01-1.23). Occurrence of major and minor complications at safety-net hospitals was associated with increased costs ($2,480 [95% confidence interval $1,178-$3,935]) compared with low-burden hospitals., Conclusion: Safety-net hospitals were associated with higher rates of failure to rescue after occurrence of tamponade, septicemia, and respiratory complications. Implementation of care bundles to tackle cardiovascular, respiratory, and renal complications may affect the discrepancy in incidence of and rescue from complications at safety-net institutions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Although short-term outcomes of endovascular and open infrainguinal revascularization in patients with peripheral arterial disease have been previously reported, 30-day readmission and resource utilization after these procedures remain unknown., Methods: We used the 2010-2014 Nationwide Readmissions Database and the International Classification of Diseases, Ninth Edition, to identify patients with peripheral arterial disease undergoing either in-hospital endovascular or open infrainguinal revascularization., Results: Of an estimated 574,201 hospitalized patients treated for peripheral arterial disease, 308,056 and 266,145 underwent lower limb endovascular and open infrainguinal revascularization, respectively. Compared with patients who underwent open revascularization, endovascular patients were more commonly female (44.8% vs 36.7%, P < .001) and older (69.5 vs 67.2 years, P < .001). Moreover, they had higher rates of 30-day readmission (15.6% vs 13.5%, P < .001), in-hospital complications (22.3% vs 20.9%, P < .001), and in-hospital index mortality (2.1% vs 1.8%, P < .001). In contrast, risk-adjusted multivariable analysis found open revascularization to be independently associated with increased odds of 30-day readmission (odds ratio, 1.13; 95% confidence interval 1.10-1.16), index complications (odds ratio, 1.23; 95% confidence interval 1.20-1.27), and mortality (odds ratio, 1.26; 95% confidence interval 1.16-1.36) compared with those who underwent endovascular revascularization. Trend analysis revealed an overall decrease in the utilization of both endovascular and open revascularization procedures in the inpatient setting., Conclusion: Despite lower rates of adverse events compared to endovascular, open infrainguinal revascularization is independently associated with increased risk of short-term readmission, complications, and mortality. These findings should be considered in the selection of appropriate surgical therapy for lower extremity arterial occlusive disease., (Copyright © 2019 Elsevier Inc. All rights reserved.)