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Rationale: Comorbidity is a significant driver of health status and healthcare utilization in chronic obstructive pulmonary disease (COPD). Obstructive sleep apnea (OSA) portends poorer outcomes, whereas obesity is protective. Objectives: We describe the prevalence and influence of these comorbidities on COPD readmissions. Methods: We collated discharge records for COPD exacerbations spanning 2010-2016 from the Nationwide Readmissions Database using Medicare's Hospital Readmissions Reduction Program criteria, with OSA-COPD overlap identified by concomitant diagnosis code for OSA. We used mixed-effects logistic regression to predict readmission odds. A cross-sectional mediation analysis was performed to evaluate the extent that OSA attenuated obesity's impact on readmission. Results: Of 1,662,983 qualifying COPD discharges, 19.1% carried a diagnosis of obesity and 12.9% had OSA, with both diagnoses present in 7.8%. In unadjusted analyses, obesity (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.03-1.05; P

BACKGROUND: National-level data of cancer patients’ readmissions after ST-segment elevation myocardial infarction (STEMI) are lacking. OBJECTIVES: The primary aim of this study was to compare the rates and causes of 30-day readmissions in patients with and without cancer. METHODS: Among patients admitted with STEMI in the United States National Readmission Database (NRD) from October 2015–December 2017, we identified patients with the diagnosis of active breast, colorectal, lung, or prostate cancer. The primary endpoint was the 30-day unplanned readmission rate. Secondary endpoints included in-hospital outcomes during the index admission and causes of readmissions. A propensity score model was used to compare the outcomes of patients with and without cancer. RESULTS: A total of 385,522 patients were included in the analysis: 5956 with cancer and 379,566 without cancer. After propensity score matching, 23,880 patients were compared (Cancer = 5949, No Cancer = 17,931). Patients with cancer had higher 30-day readmission rates (19% vs. 14%, p < 0.01). The most common causes for readmission among patients with cancer were cardiac (31%), infectious (21%), oncologic (17%), respiratory (4%), stroke (4%), and renal (3%). During the first readmission, patients with cancer had higher adjusted rates of in-hospital mortality (15% vs. 7%; p < 0.01) and bleeding complications (31% vs. 21%; p < 0.01), compared to the non-cancer group. In addition, cancer (OR 1.5, 95% CI 1.2–1.6, p < 0.01) was an independent predictor for 30-day readmission. CONCLUSIONS: About one in five cancer patients presenting with STEMI will be readmitted within 30 days. Cardiac causes predominated the reason for 30-day readmissions in patients with cancer.

BACKGROUND: To report technical and clinical 30-day results following treatment with the Zenith Alpha™ abdominal stent graft from the ZEnith alPHa for aneurYsm Repair Registry (ZEPHYR).METHODS: Multicenter, nonrandomized, single arm, core laboratory-controlled, prospective registry collecting data on the Zenith Alpha Abdominal Endovascular Graft being used in subjects with abdominal aortic aneurysms (AAA) from sites in Germany, Belgium, and The Netherlands between December 2016 and December 2019. Inclusion criteria were non-ruptured AAAs with a maximum diameter ≥50 mm or enlargement >5 mm over 6 months with an AAA neck length ≥10 mm (site reported). Primary outcome measure was treatment success at 30 days. Treatment success was defined as a combined endpoint consisting of technical and clinical success. Technical success was defined as successful stent graft delivery and deployment as well as successful removal of the delivery system. Clinical success at 30 days was defined as freedom from type I and III endoleak, aneurysm rupture, conversion to open surgery and stent graft occlusion.RESULTS: Three hundred forty-seven subjects were included from 14 sites with a median age of 73.0 years (IQR 68.0-79.0). Thirty-four patients were female (9.8%). The median AAA diameter was 58.3 mm (IQR 55.0-63.5). The median proximal neck diameter was 23.6 mm (IQR 22.0-25.2) with a median proximal neck length of 24.4 mm (IQR 15.0-34.8) and a median infrarenal neck angulation of 24.5° (IQR 15.0-35.0). The right and left common iliac diameter were 16.1 mm (IQR 14.1-19.4) and 16.2 mm (IQR 14.1-19.1), respectively. The treatment success rate at 30 days was 94.8% (N = 329). Technical success was achieved in 333 patients (96.0%). The clinical success rate at 30 days was 98.8% (N = 343). Three patients had limb occlusions at 30 day follow up (0.9%). One patient had a type Ib endoleak (0.3%). Seventy percent of vascular access approaches were percutaneous. The reintervention rate was 1.7% (N = 6) within 30 days. Indications for reinterventions were a false aneurysm at puncture site (N = 1), limb complications (N = 2), stentgraft-associated renal artery occlusions (N = 2), and an external iliac artery thrombosis (N = 1).CONCLUSIONS: Endovascular aneurysm repair using the Zenith Alpha Abdominal Endovascular Graft is effective in the short term. Long term results will be reported in the future.

Background Severe tricuspid regurgitation (TR) has limited treatment options and is associated with high morbidity and mortality. Aims We evaluated the safety and effectiveness of the Cardioband tricuspid valve reconstruction system (Edwards Lifesciences, Irvine, CA, USA) from the ongoing European single-arm, multicentre, prospective TriBAND post-market clinical follow-up study. Methods Eligible patients had chronic symptomatic functional TR despite diuretic therapy and were deemed candidates for transcatheter tricuspid repair by the local Heart Team. Results Sixty-one patients had ≥severe functional TR. At baseline, 85% of patients were in NYHA Class III-IV, 94% had ≥severe TR (core laboratory-assessed) with 6.8% EuroSCORE II and 53% LVEF. Device success was 96.7%. At discharge, 59% (pl0.001) of patients achieved ≤moderate TR and 78% had at least one grade TR reduction. At 30 days, all-cause mortality and composite MAE rates were 1.6% and 19.7%, respectively; septolateral annular diameter was reduced by 20%, where 69% of patients achieved ≤moderate TR and 85% of patients had at least one grade TR reduction (all pl0.001). Mid-RVEDD, RA volume, and IVC diameter decreased by 10% (p=0.005), 21% (pl0.001), and 11% (p=0.022), respectively; 74% were in NYHA Class I-II (pl0.001) with improvements in overall KCCQ score by 17 points (pl0.001). Conclusions In the TriBAND study, the Cardioband tricuspid system demonstrated favourable outcomes at discharge and 30 days in a challenging patient population with symptomatic ≥severe functional TR. Results showed significant reductions in annular diameter and TR severity, accompanied by early evidence of right heart remodelling and improvements in functional status and quality of life.

Bariatric surgery (BSx) is one of the most common surgical procedures in North America. Readmissions may be associated with a high burden to the healthcare system. Retrospective study of the 2016 National Readmission Database of adult patients readmitted within 30 days after an index admission for BSx. Outcomes were: 30-day readmission rate, mortality, healthcare-related utilization resources, and independent predictors of readmission. Comparison groups were index admission, readmitted, and non-readmitted patients. A total of 161,141 patients underwent BSx. The 30-day readmission rate was 3.3%. Main causes for readmission were dehydration, acute kidney injury, venous thromboembolism events, and sepsis. Readmitted patients were more likely to develop shock (0.5% vs. 0.1%; P

Introduction Intestinal-cutaneous fistulas (ICFs) constitute a major surgical challenge. Definitive surgical treatment of ICFs continues to be associated with significant morbidity. The purpose of this study was to utilize a nationwide database to define the morbidity associated with current treatment strategies in the surgical management of ICFs. Methods The 2006–2017 American College of Surgeon National Surgical Quality Improvement datasets (ACS-NSQIP) were used to assess 30-day morbidity and mortality after surgical repair of ICFs. Outcomes for emergent repair were compared to elective repair of ICFs. Results Overall, 4197 patients undergoing ICF-repair were identified. Mean age was 55.9 (SD 15.3). Patients were generally comorbid (62.9% were in ASA class III). The observed in-hospital mortality was 2.3%. However, the observed morbidity rate was 47.3%. Of the observed morbidity, 35.6% was due to post-operative infectious complications (superficial surgical site infections (SSI), deep SSI, organ/space SSI, wound disruption, pneumonia, urinary tract infection (UTI) sepsis or septic shock). The most common infectious complication was sepsis (13.1%). 30-day readmission rate was 15.3% and the 30-day reoperation rate was 11.0%. Emergent repair was associated with a sevenfold increase in mortality (11.9% vs 1.8%, P Conclusion The management of patients with ICFs is complex and is associated with significant morbidity. Half of patients undergoing surgical management of ICFs developed in-hospital complications.

Objective: The aim of this study was to provide early-term evaluation, safety, and efficacy of the novel CGuard (Inspire MD, Tel Aviv, Israel) micromesh self-expanding stent with embolic protection system (EPS) during carotid artery stenting (CAS) procedure. Materials and Methods: All patients who underwent CAS with CGuard carotid stent system from January 2018 to September 2020 in a tertiary center were prospectively evaluated. Primary endpoints included technical success and perioperative neurological events (0–48 hours). Secondary endpoint was the rate of neurologic, cardiac events, and death (major adverse event or MAE) at 30 days. Patency of CGuard, peak systolic velocity (PSV), and end diastolic velocity (EDV) were evaluated at 30 days with duplex ultrasound. Results: A total of 103 patients underwent CAS procedure. Forty patients were symptomatic, and 63 patients were asymptomatic with stenosis greater than 70%. Technical success was 100%. Local anesthesia was applied in 94 patients (93%). Embolic protection devices were used in 6 patients (5.8%). Access site complications were 1.9%. Mean internal carotid artery stenosis diameter reduced from 79.47% to 14.68%. Two patients had transient ischemic attack (1.9%) and 1 patient experienced a cerebral hyperperfusion syndrome (CHS) perioperatively. External carotid artery (ECA) occlusion occurred in 1.9%. Four patients experienced jaw claudication (3.8%) postoperatively. Mean time of operation was 41 minutes. Mean duration of hospitalization was 3.1 days. The 30-day rate of MAE was 0%. CGuard patency was 100%, mean internal carotid PSV was reduced from 251.57 to 77.29 cm/s, and mean internal carotid EDV was reduced from 154.62 to 24.63 cm/s at 30 days. Conclusion: Our study shows that CGuard stent with EPS is an effective and safe device for treatment of carotid artery stenosis with acceptable low perioperative neurologic events, even with low embolic protection device usage. Larger multicenter and randomized studies are necessary to confirm its long-term efficacy.

Unplanned readmission after total hip arthroplasty (THA) has an increasing prevalence in the United States. Readmissions are a metric for a hospital's quality of care, yet the reasons behind them are mixed. In this changing health-care environment, it is critical for institutions to identify the risk factors for unplanned readmissions following a THA. Retrospective chart review and hospital administrative database query were used to report causes, demographics, and medical comorbidities linked to a 30-day readmission after primary THA at a teaching community hospital system. This study identified 4,459 primary THA procedures, of which 96 (2.2%) were unplanned readmissions. Periprosthetic fracture (20.8%) and periprosthetic infection (17.7%) were the most common causes of readmission. Patients discharged to rehab (odds ratio [OR], 2.44; 95% confidence interval [CI], 1.36–4.37; p = 0.0026) were correlated significantly with the risk of 30-day readmission. Anemia (OR, 2.62; 95% CI, 1.44–4.79; p = 0.0016), obstructive sleep apnea (OR, 2.27; 95% CI, 1.17–4.4; p = 0.0150), and asthma (OR, 2.51; 95% CI, 1.17–5.40; p = 0.0184) were significant independent risk factors. Charlson comorbidity index (p = 0.3634) was not shown to correlate with a quicker readmission within 30 days of discharge. Patients with a history of anemia, obstructive sleep apnea, and asthma should be medically optimized before and after undergoing THA in the community setting. Implementing postsurgical emphasis on discharging patients with home care options rather than transferring them to a rehabilitation facility may prevent 30-day readmissions.

Introduction Hospital and social care suffered major alterations during the SARS-CoV-2 pandemic in the UK. Older adults were disproportionally affected by routine care disruption. To our knowledge, no data has been published so far on the impact of service disruption on 30-day readmission. Methods We performed a retrospective observational study of all patients admitted to a single east London hospital with laboratory-confirmed or clinical diagnosis of COVID-19 between 16th March and 6th April 2020. Older patients were defined as aged 80 years and over. Readmission was captured within 30 days of discharge. Comparator defined as the same period in 2019. Descriptive statistics were used. Results Three hundred and ninety-three patients were included. The majority survived to discharge (69.7%). Positive laboratory testing was similar between older and younger patients (85.7% vs 84.7%, p = NS). Mortality was significantly higher for older patients on index presentation (60.2% vs 20.3%, p Conclusions Our data shows that readmission rates in the older population of East London during the SARS-CoV-2 pandemic were largely similar to non-pandemic periods. During this period, readmission rates appear to have been driven by clinical rather than social imperatives. This suggests that adapted social care services performed well and should be reinforced for future surges.

Background Patients with gastrointestinal angiodysplasia (GIA)-related bleeding are at high risk for readmissions, resulting in significant morbidity and an economic burden on the healthcare system. Aim The aim of the study was to determine the 30-day readmission rate with reasons, predictors, and costs associated with GIA-related bleeding in the USA. Methods We queried the National Readmission Database to identify patients hospitalized with GIA-related bleeding in the year 2016 using the International Classification of Diseases, Tenth Revision (ICD-10) codes. Primary outcomes included the 30-day readmission rate, and secondary outcomes were in-hospital mortality and resource utilization for index and re-hospitalizations. We also performed univariate and multivariate cox regression analysis to identify predictors of readmissions. Results A total of 25 079 index hospitalizations for GIA-related bleeding were identified in 2016. Out of these, 5047 (20.34%) patients got readmitted within the next 30 days. The most common diagnosis associated with readmissions were related to recurrent gastrointestinal bleeding. Readmissions compared to index hospitalization has significantly higher length of stay (5.38 vs. 5.11 days, P = 0.03), but mean hospitalization charges ($52 114 vs. $49 691, P = 0.11) and mean total hospitalization costs ($12 870 vs. $12 405, P = 0.16) were similar. Patients with multiple co-morbidities, length of stay >5 days, and end-stage renal disease were found to be independent predictors for 30-day readmissions. Conclusion Our study shows that one in five patients hospitalized with GIA-related bleeding was readmitted within 30 days of index hospitalization, placing a heavy economic burden on the healthcare system. Further research identifying strategies to reduce readmissions in these patients is needed.

BACKGROUND Timely intervention in hip fracture is essential to decrease the risks of perioperative morbidity and mortality. However, limitations of the resources, risk of disease transmission and redirection of medical attention to a more severe infective health problem during coronavirus disease 2019 (COVID-19) pandemic period have affected the quality of care even in a surgical emergency. AIM To compare the 30-d mortality rate and complications of hip fracture patients treated during COVID-19 pandemic and pre-pandemic times. METHODS The search of electronic databases on 1st August 2020 revealed 45 studies related to mortality of hip fracture during the COVID-19 pandemic and pre-pandemic times. After careful screening, eight studies were eligible for quantitative and qualitative analysis of data. RESULTS The pooled data of eight studies (n = 1586) revealed no significant difference in 30-d mortality rate between the hip fracture patients treated during the pandemic and pre-pandemic periods [9.63% vs 6.33%; odds ratio (OR), 0.62; 95%CI, 0.33, 1.17; P = 0.14]. Even the 30-d mortality rate was not different between COVID-19 non-infected patients who were treated during the pandemic time, and all hip fracture patients treated during the pre-pandemic period (OR, 1.03; 95%CI, 0.61, 1.75; P = 0.91). A significant difference in mortality rate was observed between COVID-19 positive and COVID-19 negative patients (OR, 6.99; 95%CI, 3.45, 14.16; P < 0.00001). There was no difference in the duration of hospital stay (OR, -1.52, 95%CI, -3.85, 0.81; P = 0.20), overall complications (OR, 1.62; P = 0.15) and incidence of pulmonary complications (OR, 1.46; P = 0.38) in these two-time frames. Nevertheless, the preoperative morbidity was more severe, and there was less use of general anesthesia during the pandemic time. CONCLUSION There was no difference in 30-d mortality rate between hip fracture patients treated during the pandemic and pre-pandemic periods. However, the mortality risk was higher in COVID-19 positive patients compared to COVID-19 negative patients. There was no difference in time to surgery, complications and hospitalization time between these two time periods.

The aim of the current study was to assess the impact of hospital readmissions within 30-days of discharge, on long-term postoperative outcomes. All patients who underwent cardiac surgery from 2011 - 2018 were included. Patients who had transcatheter procedures, VAD, and transplant were excluded. Inverse probability of treatment weighting (IPTW) propensity scoring was used for population risk adjustment. Multivariable analysis was performed to identify association with long-term mortality and readmission. The total risk adjusted (propensity scoring with IPTW) patient population consisted of 14,538 patients divided into those who were not readmitted in 30-days (nonreadmitted) (n = 12,627) and patients who were readmitted within 30-days (30-day readmitted) (n = 1911). Following IPTW, all baseline characteristics and postoperative complications were equivalent between cohorts (SMD0.10). Patients who required intraoperative [OR 1.178 (1.05, 1.32); P = 0.006] and postoperative [1.32 (1.18, 1.48); P0.001] blood transfusions were at greater risk for 30-day readmission. Median follow-up period was 4.19 years (2.45 - 6.10). The 30-day readmission cohort had a significantly higher mortality risk during early (6 months) follow-up [HR 2.49 (2.01-3.10); P0.001] and late (60 months) follow-up [HR 1.30 (1.16-1.47); P0.001]. After risk adjustment, the 30-day readmission cohort was significantly associated with increased mortality over the study follow-up period [HR 1.62 (1.48, 1.78); P0.001]. 30-day readmissions were an independent predictor of subsequent long-term hospital readmission [HR 1.61 (1.50, 1.73); P0.001]. Patients who require 30-day readmissions following cardiac surgery are at increased risk of long-term mortality and repeat readmissions. Early postoperative hospital readmission may be a marker for worse long-term outcomes in cardiac surgery.

Purpose Despite advancements in cancer therapeutics, mortality and morbidity due to anti-cancer treatments still occur but are not frequently reported. We aimed to report the 30-day mortality and morbidity of all curative and palliative anti-cancer treatments. Patients and Methods Adults with solid and hematological malignancies from two large cancer centers in Saudi Arabia, irrespective of the cancer stage and treatment type, were included in this retrospective observational study. Results Between December 1, 2019 and February 29, 2020, 1694 patients from King Abdullah Medical City in Makkah and King Fahad Medical City in Riyadh were included in the study. Among them, 77.5% were younger than 65 years of age; 72.8% were female; the prevalence of obesity, diabetes, and hypertension was 35%, 34%, and 28%, respectively; and 66.5% of patients had breast and gastrointestinal cancers. Fifty-nine (3.5%) patients died within 30 days of receiving anti-cancer treatment. Of them, 9 (0.3%) were treated with curative intent, and 50 (3%) were treated with palliative intent. Conclusion Our results emphasize the need to address preventable metabolic changes and implement innovative, predictive, preventive, and personalized medicine (PPPM) approaches focusing on patient profiles. Reporting the 30-day outcomes of all anti-cancer treatments will also allow the identification of factors underlying mortality and morbidity and lead to an improvement in oncological outcomes via innovative programs designed to improve clinical decision-making.

Aims The Evolut PRO is a new transcatheter heart valve with an outer pericardial wrap intended to reduce paravalvular leak and facilitate tissue ingrowth. We aimed to evaluate the clinical performance and safety of the Evolut PRO valve in standard practice. Methods and results FORWARD PRO is a prospective, multinational, multicentre observational study. Transcatheter aortic valve implantation with the Evolut PRO valve (23, 26, or 29 mm) was attempted in 629 non-consecutive patients from 39 centres from February 2018 to January 2019. The primary endpoint was the rate of all-cause mortality at 30 days compared to a pre-specified performance goal. An independent clinical events committee adjudicated safety endpoints based on VARC-2 definitions. All echocardiograms were centrally assessed by an independent core laboratory (Mayo Clinic, Rochester, MN, USA). Baseline characteristics included mean age 81.7±6.1 years, 61.8% female, STS score 4.7±3.3%, and 33.6% were frail. All-cause mortality at 30 days was 3.2%, which was lower than the pre-specified performance goal of 5.5% (p=0.004). Greater than mild AR was present in 1.8% of patients at discharge. Conclusions The FORWARD PRO study confirmed the safety and efficacy of the Evolut PRO transcatheter aortic valve system with an external pericardial wrap. ClinicalTrials.gov Identifier: NCT03417011

Introduction Flap reconstructions of upper extremity defects are challenging procedures. It is important to understand the surgical outcomes of upper extremity flap reconstruction, as well as associations between preoperative/perioperative variables and complications. Materials and Methods The National Surgical Quality Improvement Program (NSQIP) database was queried for patients from 2005 to 2016 who underwent flap reconstruction of an upper extremity defect. Patient and perioperative variables were collected for identified patients and assessed for associations with rates of any complication and major complications. Results On multivariate analysis, American Society of Anesthesiologists (ASA) classification >2, bleeding disorder, preoperative steroid use, free flap reconstruction, wound classification other than clean, and nonplastic surgeon specialty were independently associated with any complications. Bleeding disorder, ASA classification >2, male gender, wound classification other than clean, and preoperative anemia were independently associated with major complications. Free flap reconstruction was associated with increased length of stay, operative time, any complications, transfusions, and unplanned reoperations. Conclusion There is an association between complications in patients undergoing upper extremity free flap reconstruction and ASA classification >2, preoperative anemia, preoperative steroid use, bleeding disorders, and contaminated wounds. Male patients may require more thorough counseling in activity restriction following reconstruction. Free flaps for upper extremity reconstruction will require increased planning to reduce the chance of complications.

BACKGROUND Discharge to nonhome settings after colorectal resection may increase risk of hospital readmission. OBJECTIVE The purpose of this study was to determine the impact of various discharge dispositions on 30-day readmission after adjusting for confounding demographic and clinical factors. DESIGN This was a retrospective cohort study. SETTINGS Data were obtained from the University HealthSystem Consortium (2011-2015). PATIENTS Adults who underwent elective colorectal resection were included. MAIN OUTCOME MEASURES Thirty-day hospital readmission risk was measured. RESULTS The mean age of the study population (n = 97,455) was 58 years; half were men and 78% were white. Seventy percent were discharged home routinely (home without service), 24% to home with organized health services, 5% to skilled nursing facility, 1% to rehabilitation facility, and

Thirty-day complications in osteonecrosis (ON) patients undergoing total hip arthroplasty (THA) are inconsistently reported. Therefore, the purpose of this study is to evaluate (1) the incidence of THA, (2) operative times, (2) length of stay, (3) reoperation rates, (4) readmission rates, and (5) complication rates, in the general vs ON THA populations. We also substratified and compared these cohorts based on ON-specific risk factors.Using the National Surgical Quality Improvement Program database, Current Procedural Terminology code 27130, International Classification of Disease, Ninth Edition code 733.42, and a 1:1 propensity score match, a total of 8344 matched ON and non-ON THA patients were identified. ON patients were also substratified based on key risk factors. The above variables were compared between the matched ON and non-ON cohorts as well as for patients with each risk factor using Pearson's chi-square and Student t-tests.The proportion of THAs performed on ON patients decreased by 35% from 2008 to 2015. Mean operative times were constant between the ON and non-ON patients (102 minutes). ON patients had shorter mean length of stay (3.1 vs 3.4 days, P = .002). Of the 17 different 30-day complications evaluated, superficial surgical site infection (1.2% vs 0.6%, P = .004), pneumonia (0.8% vs 0.2%, P = .001), transfusion (15.6% vs 5.4%, P.001), and readmission (5.1% vs 2.3%, P = .012) were higher among ON patients. ON patients with a history of corticosteroid use, higher American Society of Anesthesiologists score, and smoking were also found to have higher complication rates compared to non-ON patients with the same risk factors.This is one of the first studies to compare postoperative THA outcomes between matched ON vs non-ON patients, while also taking into consideration specific risk factors between the cohorts.

Background: Approximately 42% of patients with end-stage osteoarthritis have bilateral disease. Although bilateral total hip arthroplasty (THA) is physiologically demanding, certain patients may benefit from simultaneous rather than staged bilateral procedures. This study examines the intraoperative differences and 30-day outcomes in patients receiving bilateral THA compared with those who underwent unilateral THA. Methods: Patients undergoing THA were selected from the National Surgical Quality Improvement Program database from 2008 to 2015. Patients were selected according to those with primary and concurrent coding for Current Procedural Terminology 27130. Thirty-day complications were recorded, and multivariate analyses were performed to determine whether concurrent THA was a risk factor for poor outcomes. Results: A total of 97,804 patients and 587 patients who underwent unilateral and bilateral THA, respectively, were identified. Patients who underwent bilateral procedures were younger (57.3 vs 64.6 years, P < .001), were of lower body mass index (29.2 vs 30.2, P < .001), and had fewer comorbidities than patients who underwent unilateral procedures. Length of stay was not increased for bilateral recipients (3.13 vs 2.93 days, P = .308), although fewer were discharged to home (62.8% vs 77.6%, P < .001). The bilateral recipients required postoperative transfusions at a higher rate (29.8% vs 10.9%, P < .001) and had an increased incidence of deep wound infections on univariate analysis (1.2% vs 0.3%, P = .002). There was no increased risk of superficial infection, medical complications, or thromboembolic events for the bilateral cohort. Conclusions: Although bilateral THA recipients are younger with fewer preoperative comorbidities, bilateral THA is associated with an increased rate of transfusion in a nationwide setting. With this knowledge, specific interventions should be instituted to target these procedure-specific risks.

Whether renal artery stenting (RAS) confers benefit over medical therapy (MT) alone in patients with atherosclerotic renal artery stenosis admitted with acute coronary syndromes (ACS), congestive heart failure (CHF), or hypertensive crisis remains unknown. We identified a nationally-weighted cohort of 116,056 patients from the Nationwide Readmissions Database with a preexisting diagnosis of atherosclerotic renal artery stenosis and an index hospitalization diagnosis of ACS, CHF, or hypertensive crisis, and propensity-matched on the likelihood of undergoing inpatient RAS. Thirty-day readmission rates, index hospitalization complications, hospital lengths-of-stay, and cost were compared between treatment groups. Overall, all-cause, nonelective 30-day readmission rates did not differ between RAS and MT alone (18.2% vs 18.7%, respectively, p = 0.49). RAS was associated with higher index rates of acute kidney injury, major bleeding, transfusion, and vascular complications, and were similar irrespective of index hospitalization diagnosis. Index hospitalization length of stay (6 vs 4 days; p0.001) and cost ($23,020 vs. $11,459; p0.001) were higher with RAS. In conclusion, nearly 1-in-5 patients hospitalized with atherosclerotic renal artery stenosis and ACS, CHF, or hypertensive crisis were readmitted within 30-days. Index hospitalization complications occurred more frequently among those treated with RAS than MT alone, but the likelihood of readmission did not differ by treatment strategy.

OBJECTIVEThe risk of readmission after brain tumor resection among pediatric patients has not been defined. The authors’ objective was to evaluate the readmission rates and predictors of readmission after pediatric brain tumor resection.METHODSNationwide Readmissions Database (NRD) data sets from 2010 to 2014 were searched for unplanned readmissions within 30 days of the discharge date after pediatric brain tumor resection. Patient demographic variables included sex, age, expected payment source (Medicaid or private insurance), and median annual household income. Readmission events for chemotherapy, radiation therapy, or further tumor resection were not included.RESULTSOf 282 patients (12.7%) readmitted within 30 days of the index event, the median time to readmission was 10 days (IQR 5–19 days). The most common reason for readmission was hydrocephalus, which accounted for 19% of readmission events. Other CNS-related complications (24%), surgical site infections or septicemia (14%), seizures (7%), and hematological disorders (7%) accounted for other major readmission events. The median charge for readmission events was $35,431, and the median length of readmission stay was 4 days. In multivariate regression, factors associated with a significant increase in readmission risk included Medicaid as the primary payor, discharge from the index event with home health services, and fluid and electrolyte disorders during the index event.CONCLUSIONSMore than 10% of pediatric brain tumor patients have unplanned readmission events within 30 days of discharge after tumor resection. Medicaid patients and those with preoperative or early postoperative fluid and electrolyte disturbances may benefit from early or frequent outpatient visits after tumor resection.

Total knee arthroplasty (TKA) is the second most common surgery performed in Canada. Understanding and improving quality metrics associated with such high-volume procedures is of utmost importance to maximize value within the healthcare system, which is a balance between cost and quality. Although rates and predictors of hospital readmission and emergency department (ED) visits following TKA have previously been described in privatized healthcare settings, few studies have evaluated trends in length of stay (LOS), hospital readmissions, and ED visits following TKA in a universal single-payer system.Using data from a provincially held and validated registry, the Institute for Clinical and Evaluative Sciences, we undertook a review of all 205,152 TKAs performed in the province of Ontario, Canada, between 2003 and 2016. We determined temporal trends in utilization, LOS, readmissions, and ED visits and evaluated patient and provider predictors of hospital readmissions and ED visits using multivariate logistic regression modeling. We also grouped and described the most common reasons for readmission and ED visits based on the available International Classification of Diseases, Ninth Revision and Tenth Revision coding information.LOS decreased significantly over the study period (P.0001), from a median of 5 days (10th percentile 3 days, 90th percentile 8 days) in 2003 to a median of 3 days (10th percentile 2 days, 90th percentile 4 days) in 2016. All-cause 30-day readmissions did not change significantly over the study period, but the rate of ED visits increased significantly over time. Predictors of 30-day readmission following TKA included older age, male gender, lower income quartile, not having a postoperative visit with a primary care physician (PCP), increased comorbidities, longer LOS, urgent or revision surgery, admission to a teaching hospital, and discharge to an inpatient rehabilitation facility. Variables that predicted increased odds of an ED visit included older age, male gender, lower income quartile, not having a postop visit with a PCP, increasing comorbidities, year of surgery, longer LOS, and revision surgery. Admission to a teaching hospital and discharge to an inpatient rehabilitation facility showed a trend toward increased odds of an ED visit.We identified a significant increase in ED visits following TKA in Ontario between 2003 and 2016, with no corresponding increase in hospital readmissions despite a significant temporal trend toward shorter LOS. Predictors of ED visits and readmissions were similar, including male gender, lower income, higher comorbidities, and lacking a PCP visit postoperatively. Increased rates of ED visits following TKA in Ontario represent a quality problem, as they are associated with increased cost to the public healthcare system without any substantial benefit. Interventions aimed at redirecting patients from the ED for minor postoperative concerns should be investigated, as this is likely to improve care by reducing costs, improving efficiency, and enhancing patient experience.

Many epidemiological studies have established an association between environmental exposure and clinical outcome for hospital admissions. However, few studies have explored the impact of environmental factors, such as ambient air pollution and meteorological factors, on hospital readmissions using predictive analysis. In this study, we aimed to develop a model to predict unplanned hospital readmissions within 30 days of discharge based on the common data model considering weather and air quality factors. Moreover, we validated the proposed model externally. We developed and compared the following machine learning methods: decision tree, random forest, AdaBoost, and gradient boosting machine–based models. We performed 10-fold cross-validation for internal validation, and external validation was performed by applying the model to unseen data. The performance of the prediction model was evaluated using the area under the receiver operating characteristic curve. PM10, rainfall, and maximum temperature were the weather and air quality variables that most impacted the model. Among the four machine learning models, the AdaBoost-based model demonstrated the best performance and was the most accurate in predicting the readmission of patients with musculoskeletal diseases. External validation demonstrated that the model based on weather and air quality factors is transportable.

Background:. COVID-19 led to the reconfiguration of U.K. orthopaedic trauma services because surgical capacity was threatened in acute centers. We report the 30-day mortality of proximal femoral fractures in older adults treated at an elective orthopaedic center. Methods:. Patients >60 years old who presented with a proximal femoral fracture to any of 4 sites in the regional trauma network were transferred to our elective center for emergency surgery. Care was modeled according to the National Institute for Health and Care Excellence guidelines, and efforts were made to treat all patients within 36 hours. Data were collected prospectively, and mortality outcomes were recorded. Results:. Of the 192 patients who presented to the elective orthopaedic center, 167 were treated there. The median age of the latter patients was 88 years (interquartile range, 83 to 79 years). The median Charlson Comorbidity Index was 4 (interquartile range, 4 to 6). The median time from emergency department admission to surgical treatment was 24.5 hours (interquartile range, 18.8 to 34.7 hours). The 30-day rate of mortality was 10.2%. A total of 29 (17.4%) tested positive for COVID-19 during their admission, of whom 10 died, for a case-fatality rate of 34.5%. There were no significant differences in age (p = 0.33) or Charlson Comorbidity Index (p = 0.13) between patients who tested positive and those who did not. There was no significant difference in age between those who tested positive and died and those who tested positive and did not die (p = 0.13), but there was a significant difference in Charlson Comorbidity Index between those subgroups (p = 0.03). Conclusions:. During a pandemic, an elective orthopaedic center can be reconfigured to a surgical center for older patients with proximal femoral fractures with acceptable health-care quality outcomes. Level of Evidence:. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: The aim of this study was to determine the cause of death in patients who died within 30 days after the first dose of immunotherapy. Methods: The data of 1432 patients treated with immunotherapy in six tertiary referral hospitals were retrospectively analyzed. Results: It was determined that 34 (2%) of the patients died within 30 days after the first dose of immunotherapy. Death occurred in all patients who received palliative therapy, and most patients (88%) received immunotherapy as second- or subsequent-line of therapy. The most common cause of death was disease progression and thromboembolic events. Conclusion: Preliminary results of the current study might give some clues to define the patient population in whom the fatal side effects of immunotherapy might be encountered.

Aims Sarcopenia (low muscle mass - SM) and myosteatosis (low muscle quality - SM-RA) are associated with poor outcomes after elective cancer surgery. Body composition parameters have not been explored in emergency surgery and may offer additive value to risk prediction scores. This multicentre study assessed the association of body composition and survival after emergency laparotomy. Methods A retrospective longitudinal cohort of 674 patients, across 10 hospitals in southern England were recruited (NCT03534765). All patients underwent emergency laparotomy, fulfilling NELA criteria, between August 2016 and November 2017. Pre-operative CTs were blindly analysed using L3 slices, assessing SM and SM-RA. Regression analysis was used to assess associations of body composition and 30-day mortality. Results Six hundred and ten patients were included [283(46%) men, median(IQR) age 71 years (57-79)]. P-POSSUM and NELA predicted mortality was 7% and 4.5% respectively, with a length of stay of 15 days (9-24), 30-day mortality of 7.8% and 1-year mortality of 18.9%. Significant univariate associations between 30-day mortality and age (OR1.04 (1.02-1.07);p=0.001), Charlson score (OR 6.84 (1.64-28.55);p=0.008), P-POSSUM (OR 1.03 (1.02-1.05);p Conclusions Sarcopenia and myosteatosis are associated with increased mortality in patients undergoing emergency surgery. Body composition should be considered as an objective adjunct to traditional risk assessments, further informing the shared-decision making process around emergency surgery.

Objective: Hypertensive crisis is a life-threatening condition that leads to poor patient outcomes if not treated urgently. We evaluate the all-cause 30-day readmission rate, resource utilization, predictors of readmission, and the most common causes for readmission in patients admitted with hypertensive crisis. Methods: Using the National Readmission Database 2018, patients ≥18 years of age admitted with the principal diagnosis of the hypertensive crisis were included in the study. The primary outcome was the all-cause 30-day readmission rate in these patients. Results: We identified 129,239 patients as index admissions. The mean age of index patients was 61±0.14 years, and females were 56.6%. The 30-day readmission rate was 10.6 % (13,768± 355). The in-hospital mortality rate was 0.2 % for index admissions and 1.5 % for readmissions. The cumulative length of stay (LOS) for all readmitted patients was 62,046± 1,802 days. The cumulative total cost of hospital services in readmitted patients was 155 ± 4.6 million USD. Age Conclusion: In conclusion, the 30-day readmission rate in patients with hypertensive crisis is high (10.6%), with hypertensive crisis and CHF as the most common causes. Resource utilization is also high, with many potential avoidable days and costs. Future strategies should address underlying factors, especially socioeconomic factors.

The association between malignancy and readmission after Takotsubo syndrome (TTS) hospitalization has not been fully described. We sought to examine the rates, cause, and cost of 30-day readmissions of TTS, with or without malignancy, by utilizing Nationwide Readmissions Databases from 2010 to 2014. We identified 61,588 index hospitalizations for TTS. TTS patients with malignancy tended to be older (70.6 ± 0.2 vs. 66.1 ± 0.1, p &lt, 0.001), and the overall burden of comorbidities was higher than in those without malignancy. TTS patients with malignancy had significantly higher 30-day readmission rates than those without malignancy (15.9% vs. 11.0%, odds ratio (OR), 1.35, 95% confidence interval (CI), 1.18–1.56). Non-cardiac causes were the most common causes of readmission for TTS patients with malignancy versus without malignancy (75.5% vs. 68.1%, p &lt, 0.001). The 30-day readmission rate due to recurrent TTS was very low in both groups (0.4% and 0.5%, p = 0.47). The total costs were higher by 25% (p &lt, 0.001) in TTS patients with vs. without malignancy. In summary, among patients hospitalized with TTS, the presence of malignancy was associated with increased risk of 30-day readmission and increased costs. These findings highlight the importance of optimized management for TTS patients with malignancy.

Introduction: although sepsis is one of the most important causes of death in hospitalized patients, information on early predictive factors for predicting mortality and morbidity is limited. The aim of this study was to determine the relationship between defined arterial blood gas parameters and 30-day mortality in adult patients aged 65 years and older who were admitted to the emergency department and diagnosed with sepsis. Methods: arterial blood gas parameters of patients older than 65 years who were diagnosed with sepsis in the emergency department during the 5-month period between March and August 2017 were analyzed retrospectively. The relationship between pH, lactate, anion gap, bicarbonate and base-excess and 30-day mortality was analyzed. Results: a total of 103 elderly patients with sepsis were included in the study. Fifty-eight patients (56.3%) were female and the mean age was 77.74 +/- 8.45 years (range: 65-99 years). Twenty-two patients (21.4%) died within 30 days. The admission "Quick Sepsis-related Organ Failure Assessment" values were found to be 2 or more in 32 patients (31.1%). Bicarbonate (p=0.001), lactate (p, NA

Background Because of the emergence of readmission-related Medicare penalties, efforts are being made to identify and reduce patient readmissions. The purpose of this study was to compare rates and risk factors for 30-d readmission and hospital length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) among patients treated for carotid artery stenosis in Pennsylvania. Materials and methods Data were from the Pennsylvania Health Care Cost Containment Council (PHC4). We identified 15,966 patients who underwent CEA (n = 13,557) or CAS (n = 2409) in Pennsylvania between 2011 and 2014. Logistic regression was used to determine risk factors for 30-d readmission, whereas linear regression was used to model factors influencing LOS. Propensity score analysis was used to control for imbalanced covariates between procedures. Results Thirty-day readmission rates in Pennsylvania after CEA and CAS for carotid artery stenosis were similar (9.8% and 9.6%, respectively; P = 0.794). Not home discharge destination, Charlson comorbidity index ≥2, and LOS >1 d were all significantly associated with readmission risk. Procedure type (CEA or CAS) did not significantly influence risk. A significant difference in LOS was found between CEA and CAS, but the magnitude of the difference was small (2.38 for CAS versus 2.59 for CEA; P = 0.007). Black race, urgent and emergent cases, and not home discharges significantly increased LOS by notable amounts (1, 1.5, 3.9, and 1.9 d, respectively). Conclusions Carotid artery stenosis patients in Pennsylvania undergoing CEA or CAS had similar 30-d readmission rates. Although LOS was significantly different, the magnitude of the difference was not large.

The purpose of the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair (TEVAR) for dissection project is to assess the effectiveness of TEVAR for type B dissection by evaluation in a prospective quality improvement registry. Here we describe the project cohort and 30-day outcomes of TEVAR for both acute dissection (AD) and chronic dissection (CD) patients and focus specifically on outcomes of uncomplicated AD patients based on timing of treatment.Summary statistics were performed comparing patients with AD (30 days) and patients with CD. Both groups were further divided into those with complicated (ie, malperfusion or rupture) or uncomplicated presentation. Further subdivision of the uncomplicated AD patients into treatment at ≤48 hours,48 hours to 7 days, ≥7 days to ≤14 days, and14 days to 30 days was performed. Kaplan-Meier analysis was performed for 30-day survival and freedom from reintervention.Data for 397 patients (204 AD patients and 193 CD patients) were collected from 40 institutions. Overall, AD patients were younger than CD patients (58.8 vs 62.2 years; P = .003). Technical success, including coverage of the primary entry tear, was 98.0% for AD patients and 99.0% for CD patients, with a trend toward a higher 30-day mortality in AD patients (AD, 9.3%; CD, 5.2%; P = .126). Any degree of procedure-related spinal cord ischemia occurred in 4.4% of AD patients vs 2.1% of CD patients (P = .261), with a deficit at discharge in 3.4% of AD patients vs 0.5% of CD patients (P = .068). Disabling stroke occurred in 2.5% of AD patients vs 1.6% of CD patients (P = .725); retrograde type A dissection occurred in 1.1% of AD patients vs 2.6% of CD patients (P = .412). There was a trend toward a lower freedom from reintervention in AD patients (90.7% vs 94.8%; P = .13). In uncomplicated AD patients, rapid aortic expansion was more common in the treatment groups of ≥7 days to ≤14 days and14 days to 30 days compared with those treated within 7 days of dissection (P = .042). The uncomplicated AD cohorts based on timing of treatment were otherwise similar in demographics and presentation, with no significant differences in 30-day mortality or serious complications, such as spinal cord ischemia, stroke, or retrograde type A dissection. The 30-day reintervention rate for uncomplicated AD patients was 5.8%, with no apparent differences in reintervention rates according to timing of treatment of initial TEVAR.As expected, AD patients demonstrated a trend toward a higher 30-day mortality and lower freedom from reintervention compared with CD patients. Mortality at 30 days after TEVAR for uncomplicated AD was 5.8%, and there were no clear patterns in mortality or reintervention based on timing of treatment. Further study and evaluation at longer follow-up are needed to determine the impact of timing of intervention in uncomplicated AD patients.

Thirty-day readmission rates has been increasingly used by clinicians, hospital administrators, and policy makers as a metric for the quality of care. However, the 30-day readmission rates may be affected by other factors intrinsic to the patient and may not be a good measure of the quality of care provided by the hospital. In this review, we examined the quality of the 30-day readmissions rate as a quality metric for the quality of care provided to patients with aneurysmal subarachnoid hemorrhage (SAH). It has been shown that in this patient population, 30-day readmission rate primarily captures values, such as the number of comorbidities, disease severity, and discharge dispositions. There is little association between SAH 30-day readmission rates and mortality. However, 30-day readmissions may be reduced by increasing early discharge surveillance, providing readmission reduction programs to patients discharged to medical facilities as well as to home, and identifying patients most at risk for readmission.

BACKGROUND/OBJECTIVE The aims of this study were to describe the rates and characteristics of nonelective 30-day readmission among adult patients hospitalized for acute gout and to assess predictors of readmission. METHODS We analyzed the 2017 Nationwide Readmission Database. Gout hospitalizations were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification code. Hospitalizations for adult patients were included. We excluded planned or elective readmissions. We utilized χ2 tests to compare baseline characteristics between readmissions and index hospitalizations. We used multivariate Cox regression to identify independent predictors of readmissions. RESULTS A total of 11,727 index adult hospitalizations with acute gout listed as the principal diagnosis were discharged alive and included. One thousand five hundred ninety-four (13.6%) readmissions occurred within 30 days. Acute gout was the most common reason for readmission. Readmissions had higher inpatient mortality (2.4% vs 0.1%, p < 0.0001), greater mean age (68.1 vs 67.0 years, p = 0.021), and longer hospital length of stay (5.9 vs 3.8 days, p < 0.0001) compared with index hospitalizations. Charlson Comorbidity Index scores of ≥2 (score 2: adjusted hazards ratio [AHR], 1.67; p = 0.001; score ≥3: AHR, 2.08; p < 0.0001), APR-DRG (All Patients Refined Diagnosis Related Groups) severity levels ≥2 (level 2: AHR, 1.43; p = 0.044; level 3: AHR, 1.83; p = 0.002; level 4: AHR, 2.38; p = 0.002), admission to metropolitan hospital (AHR, 1.83; p = 0.012), atrial fibrillation (AHR, 1.31; p = 0.004), and anemia (AHR, 1.30; p = 0.001) were significantly associated with 30-day readmissions. CONCLUSIONS Acute gout readmissions were associated with worse outcomes compared with index hospitalizations. Charlson Comorbidity Index scores ≥2, APR-DRG severity levels ≥2, admission to metropolitan hospital, atrial fibrillation, and anemia were significant predictors of readmission.

In March 2020 Coronavisus-19 pandemic led to significant changes in operations in healthcare in the United Kingdom with national lockdown measures imposed to help protect the vulnerable and prevent transmission. Those deemed vulnerable fall into the cohort of patients at risk of fragility fractures such as fracture neck of femur (NOF). British Orthopaedic Association released guidelines advising that NOF fractures should continue to be treated urgently. Aim Our unit aimed to identify changes in NOF caseload during the national lockdown and identify if Nottingham Hip Fracture Scores (NHFS) were reliable at predicting 30-day mortality in COVID-19 positive patients. Methods A retrospective observational study identifying NOF admissions over a 6-week period in 2020 during lockdown period, where demographics, NHFS, and 30-day mortality rates were compared against the same period in 2019. Results There was a reduction in NOF admissions by 17.8% (55 vs 67). No significant difference in patient demographics between groups. 30-day mortality rates were not significantly increased in 2020 compared with 2019. COVID-19 positive patients had significantly increased 30-day mortality rates (54%, p = 0.001) compared to COVID-19 negative (9.1%, p = 0.395) and 2019 (6%). Discussion NHFS was not reliable as a predictor for 30-day mortality in COVID-19 positive patients. Our unit reports increased mortality rates in NOF patients with covid-19 infection. This adds to the building evidence that COVID-19 is an independent predictor for mortality in NOF patients irrespective of NHFS. This should be communicated to patients who are admitted to hospital with NOF and units should continue with efforts to prevent hospital acquired COVID-19 infection.

Background Octogenarians are at an increased risk of morbidity and mortality following various surgeries, but this has not yet been well explored in octogenarians undergoing revision total shoulder arthroplasty (RTSA). Thus, the purpose of this study was to analyze whether octogenarians undergoing RTSA are at an increased risk of 30-day postoperative complications, readmissions, and mortality relative to the younger geriatric population. Methods Data of patients who underwent RTSA from 2013 to 2018 were obtained from a large de-identified database. Patients were divided into two cohorts: ages 65–79 and ages 80–89. Demographic data, comorbidities, and postoperative complications were collected and compared between the two cohorts. Bivariate and multivariate analyses were performed. Results On bivariate analyses, patients aged 80–89 were more likely to develop pulmonary embolism (p = 0.014) and extended length of stay more than 3 days (p = 0.006) compared to the cohort aged 65–79. Following adjustment on multivariate analyses, 80–89 years old patients no longer had an increased likelihood of pulmonary embolism or extended length of stay compared to the 65–79 age group. Octogenarians were not found to have higher rates of 30-day readmissions (p = 0.782), mortality (p = 0.507), reoperation (p = 0.785), pneumonia (p = 0.417), urinary tract infection (p = 0.739), or sepsis (p = 0.464) compared to the cohort aged 65–79 following RTSA. Conclusion Age greater than 80 should not be used independently as a factor for evaluating whether a geriatric patient is a proper candidate for RTSA.

Background Day surgery has been gradually accepted by health professions globally, which can shorten the hospital stay and reduce medical costs. The ambulatory laparoscopic cholecystectomy (LC) has been performed in China since over 10 years. However, few studies focus on its 30-day unplanned readmission rate of ambulatory LC and no standard of unplanned readmission rate for that now. Purpose This study aimed to evaluate the unplanned readmission rate and the reasons readmission after ambulatory LC in a tertiary hospital, which is the earliest ambulatory surgery implementation place in western China. Methods A retrospective analysis was conducted. The patients who underwent ambulatory LC from September 2015 to September 2019 in West China Hospital were screened. The 30-day unplanned readmission rate was calculated as the first outcome. The reasons for unplanned readmission were analyzed and classified as the second outcome. Results The study included 3,014 patients, and the unplanned readmission rate was 1.53%. The rate of patients diagnosed with cholecystolithiasis with cholecystitis was significantly higher in the unplanned readmission group (73.9% vs. 48.9%, p=0.003), and medical cost of unplanned readmission patients was significantly more than that of non-readmission patients (8,102.4±1,375.7 Yuan vs. 7,574.61±10,14.0 Yuan; p=0.008). It was observed that 71.7% readmission happened in the first seven days. Wound problems (60.9%) and abdominal pain (26.1%) went the two main reasons for unplanned readmission. Conclusions The analysis revealed that the unplanned readmission rate of 1.53% was low for ambulatory LC. Some causes of unplanned readmission, such as abdominal pain and wound site pain, wound exudate could be reduced by some simple interventions of the clinical professions.

Introduction: Due to their exclusion from most clinical trials, outcomes of carotid revascularization via a carotid endarterectomy (CEA) or carotid artery stenting (CAS) among octogenarians are not well studied. Herein, we present analysis of thirty-day stroke and mortality of patients aged ≥ 80 using real-world data from a national surgical quality registry. Methods: The National Surgical Quality Improvement Program (NSQIP) targeted dataset for CEA and CAS was queried for patients aged ≥ 80 undergoing CEA and CAS between 2012-2018. Results: A total of 94 and 2,656 patients aged ≥ 80 with symptomatic carotid stenosis undergoing CAS and CEA (respectively) were identified. Patients in the CAS group were more likely to be over 90 (p=0.006). Patients in the CAS group were more likely to have high-risk anatomy (p Conclusion: Real world analysis from a surgical quality registry show that both CAS and CEA are associated with optimal 30-day outcomes among octogenarians with symptomatic carotid stenosis.

Introduction: National-level data of cancer patients’ readmissions after a ST-segment elevation myocardial infarction (STEMI) are lacking. Objectives: The primary aim of this study was to describe rates and causes of 30-day readmissions in this population. Methods: Among patients who were admitted with STEMI in the United States National Readmission Database (NRD) from October 2015-December 2017, we identified patients with the diagnosis of active breast, colorectal, lung or prostate cancer. The primary endpoint was 30-day unplanned readmission rate. Secondary endpoints included in-hospital outcomes during the index admission and causes of readmissions. A propensity score model was used to compare the outcomes of cancer and no cancer patients. Results: A total of 385,522 patients were included in the current analysis (Cancer= 5,956, No Cancer=379,566). After propensity score matching, 23,880 patients were compared (Cancer=5,949, No Cancer=17,931). Cancer patients had higher 30-day readmission (19% vs 14%, p Conclusions: About one in five cancer patients presenting with STEMI will be readmitted within 30 days. Cancer patients’ 30-day readmissions are still predominantly cardiac-related but with a higher proportion of admissions for infectious, cancer-related and bleeding and than those without cancer.

Introduction: Heart failure (HF) readmission quality metrics disproportionately impact reimbursement in safety net hospitals. Prior research has demonstrated the effect of medical comorbidities on readmission, however, there is a paucity of data on predictors of readmission in vulnerable and underserved HF patients. We sought to evaluate the effect of demographics, medical and social comorbidities on risk of 30 day readmission in an academic safety net hospital in San Francisco. Methods: We performed a retrospective chart review from 2018 to 2020. Patients were included if treated for HF while on inpatient cardiology or medicine services and were assigned an ICD-10 discharge code for HF. Patients less than 21 years old were excluded. Demographics and comorbidities were obtained through evaluation of ICD-10 discharge codes and chart review. Multivariate modeling was used to determine predictors of 30 day readmission. Results: The study population included 383 patients in which the mean age was 60±13 years and 73% (n=282) were male. 44% (170) were Black, 23% (88) were Latinx, 33% (127) were not housed, 97% (371) had public insurance, and 21% (81) had a diagnosis of mental illness. 46% (177) had CAD, 76% (291) hypertension, and 36% (177) DM. Substance use was common with 30% (114) using methamphetamines, 36% (138) cocaine, 18% (69) opioids, and 35% (135) alcohol. On multi-variate analysis, EF less than 40% (75%, 285) was the only medical comorbidity associated with an increased risk of readmission (OR 1.86, 1.1-3.1, p= 0.018). Social variables associated with increased risk of readmission included identifying as Black (OR 2.26, 1.03-5.0, p= 0.043) or Latinx (OR 3.43, 1.41-7.59, p= 0.006), homelessness (OR 3.02, 1.76-5.18, p= Conclusion: Race, housing status and substance use were more strongly associated with readmission risk than medical comorbidities in a population of urban, vulnerable and underserved HF patients. Interventions to improve HF readmission metrics should consider addressing racial and social disparities in similar populations.

Introduction: Watchman device is an alternative for anticoagulation in atrial fibrillation (AF) patients for stroke prevention but there is paucity of data on 30-day readmission trends and factors influencing it. Methods: We queried the 2016-2017 National Readmission Database for all adult AF patients, who had procedure done in January to November and discharged alive, using ICD10 code of 02L73DK. We divided the study population into deciles and used the annual procedure volume cut-off of 20 to compare the lowest volume decile with rest of the study population. Hierarchical multivariable logistic regression model was created to identify predictors of 30-day readmission and hospitals were included as random effect. Results: A total of 4565 and 9219 procedures were included for 2016 and 2017; respectively. Overall readmission rate was 1287 (9.3%) and of these 43 (3.3%) died on readmission. The 30-day readmission rate in 2017 was 906 (9.8%) compared to 381 (8.4%) in 2016 (p = 0.053) but the mortality associated with readmission was significantly higher in 2017 at 38 (0.42%) compared to 5 (0.11%) in 2016 (p=0.01). The proportion of patients with Charlson co-morbidity index ≥5 was significantly higher in 2017 at 1177 (12.8%) compared to 384 (8.4%) in 2016 (p Conclusions: Thirty-day readmission rate and mortality has been increasing along with the procedural volume which could be related to patients with higher number of co-morbidities receiving the device. Lower procedural volume of the hospital is an independent predictor of readmission.

Introduction: Safety net hospitals are more likely to be penalized for heart failure (HF) readmissions. There is limited evidence as to whether readmission reduction strategies are effective in this setting. We hypothesized that a discharge checklist would reduce readmissions in an urban safety net hospital. Methods: We implemented a novel HF discharge checklist in an academic safety net hospital in San Francisco from October 2018 to April 2019. The checklist included 1) achievement of euvolemia based on physical exam, 2) prescription of guideline-directed medical therapy, and 3) establishment of scheduled follow-up within 7 days of discharge. All HF patients who were discharged with the checklist in the 6 month study period were retrospectively compared to all HF patients discharged in the 6 months prior to the implementation of the checklist. The primary outcome was the 30-day readmission rate and multivariate modeling was used to assess the significance of each checklist component. Results: Demographics were similar between the intervention (n=118) and control (n=265) groups. Of all 383 patients, mean age was 60±13 years, 102 (27%) patients were women, 170 (44%) were black, 88 (23%) were latinx, 127 (33%) were not housed, 208 (54%) used illicit substances, and 289 (76%) had ejection fraction ≤ 40%. Use of the checklist was associated with a 13.3% absolute reduction in the 30-day readmission rate (33.6% vs 20.3%, p=0.009). The intervention group was more likely to be discharged on guideline-directed medical therapy (54% vs 25%, p Conclusions: A novel, inexpensive discharge checklist increased the prescription of guideline-directed medical therapy and significantly reduced 30-day HF readmissions in a safety net hospital.

Background: Heart failure (HF) is one of the costliest conditions in the US with immense public health interest to examine and improve the value of care. We sought to characterize current payments spanning the index hospitalization through 30-days post-discharge for Medicare beneficiaries with HF. Methods: Using Medicare fee-for-service administrative claims data, we identified patients hospitalized with HF from 2016-2018 with the following primary discharge diagnoses (ICD-10 codes): systolic HF (50.2 and 50.4), diastolic HF (50.3), hypertensive heart disease (HHD) with HF (I11), and HHD with HF and chronic kidney disease (CKD) (I13). Coding patterns over time across these four groups, mean 30-day episode of care spending overall, and proportion of total costs allocated to the index hospitalization and post-acute care were analyzed. Results: The study sample included 174,539 patients hospitalized with systolic HF; 163,071 diastolic HF; 221,820 HHD with HF; and 359,950 HHD with HF and CKD. Over time, there was a substantial increase in the use of the HHD with HF +/- CKD codes, accounting for 52% of HF hospitalizations in 2018 (Figure). We found substantial spending on 30-day episode for HF with nearly 2-fold variation across mean spending. Overall, 30-day episode spending was significantly higher for HHD with HF and CKD as compared to other diagnoses. Across all codes, the index hospitalization accounts for 70% of total episode spending while 30% is accounted for by post-acute care spending (Table). Conclusions: This patient episode-level analysis of contemporary Medicare beneficiaries suggests several areas to improve the value of HF care. The 30-day episode of care spending for heart failure hospitalizations is substantial with more than 2-fold variation. The impact of alternative payment models on HF outcomes and spending remains an important area for ongoing investigation.

Background Esophageal variceal hemorrhage (EVH) is a potentially fatal Gastro-intestinal emergency. The aim of this study was to evaluate the in-hospital mortality rate, 30-day readmission rate, and its impact on mortality and morbidity in EVH patients. Methods A descriptive study (prospective) was conducted at the Gastro-hepatology department of AIMS Hyderabad from September 2019 to January 2020. Adults with EVH were included in the study. The clinical characteristics and laboratory data at admission were documented, based on which MELD and CTP scores were calculated. The surviving patients were then followed via telephone after 30 days and readmission and its reasons, mortality, and morbidity within 30-days were determined. Results A total of 95 EVH patients were included in the study, out of which 74.7% were males. The mean age of the participants was 49.56 years. The etiology was Hepatitis C in 62 (65.3%) patients. The in-hospital mortality was 5 (5.3%). Of those who survived, 17 (17.5%) had readmissions with rebleeding as cause in 7 (7.4%) patients. The rest of the patients were admitted with other complications of end-stage liver disease. Conclusions The all-cause 30-day readmission rate after EVH was 17.5% with more than one-third of the cases due to rebleeding. The readmission was not associated with higher rates of mortality (in-hospital mortality rate vs readmission mortality rate).

Introduction Stroke is a major and feared complication after transcatheter aortic valve implantation (TAVI). So far it is unknown, weather the valve deployment system itself has an impact on the incidence of periinterventional stroke. We sought to identify the incidence of 30-day stroke after transfemoral TAVI with self-expandable (SE) and balloon-expandable (BE) valves and performed a meta- and network meta-analysis to analyze differences related to the valve deployment system. Methods Overall 2706 articles were searched comparing directly the performance of SE and BE TAVI valves, from which 7 were included for analysis (one randomized controlled trial, 6 propensity score matching studies) with a total number of 2488 patients. Meta-analysis used random effects model and reported risk ratios (RRs). To compare different type of valves a random-effects network meta-analysis based on a frequentist framework for indirect and mixed comparisons was applied and reported odds rations (ORs). Using P-Score the relative ranking probability of each valve was estimated and the hierarchy of competing valves was obtained. Results Thirty-day incidence of stroke was 1.9% in SE (22 out of 1139, Medtronic CoreValve, Medtronic Evolut R and Pro, Boston Scientific ACURATE neo and St. Jude Medical Portico) and 3.1% in BE TAVI valves (42 out of 1349, Edwards Sapien 3 and XT) resulting in a RR of 0.65, (95% confidence interval (CI) 0.51 to 0.82). In accordance with the estimated P-Score CoreValve was the best effective for a reduction of 30-day stroke (72,5%) whereas the worst were Sapien 3 and XT (19.%). Combined direct and indirect evidence showed no superiority of CoreValve compared with Sapien valves (OR 0.469, 95% CI 0.13–1.64) concerning 30-day stroke incidence. Conclusion Our meta-analysis indicates a higher thirty-day incidence of stroke after TAVI with BE valves compared to SE valves. Furthermore, we could not find evidence for superiority of a specific valve system. Randomized controlled trials with head to head comparison of SE and BE valves are needed to address this open question. Funding Acknowledgement Type of funding source: None

Background and aims Nearly half of all heart failure patients have heart failure with preserved ejection fraction (HFpEF). Due to differences in pathophysiology of heart failure with preserved and reduced ejection fraction, as well as a paucity of studies, the treatment of hHFpEF remains a challenge. We aimed to determine the rate of hospital readmission within 30 days of acute or acute on chronic HFpEF and its impact on mortality and health care utilization in the United States. We also focused on patient demographics as well as independent variables affecting readmission. Methods We performed a retrospective study using the Agency for Health-care Research and Quality's Health-care Cost and Utilization Project (HCUP), Nationwide Readmission Database (NRD) for the year of 2017 (data on approximately 18 million hospital stays at 2,454 hospitals in the United States). We collected data on hospital readmissions of 60,514 adults who were hospitalized for acute or acute on chronic diastolic heart failure and discharged. The primary outcome was the rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, and resource use (length of stay, total hospitalization costs and charges). Independent risk factors for readmission were identified using Cox regression analysis. Results The 30-day rate of readmission was 21%. Only 1,175 (9.17%) of readmissions were associated with an admitting diagnosis of acute on chronic diastolic heart failure. The most common readmission diagnosis was hypertensive chronic kidney disease with heart failure (1,245; 9.7%). Readmission cases were associated with increased in-hospital mortality compared to index admission (7.9% vs 2.9%, p=0.000). Readmission was associated with a total of 81,997 hospital days. Total health care in-hospital economic burden was $206 million (in costs) and $779 million (in charges). Significant predictors of increased thirty-day readmission were Medicaid insurance (1.15, 1.05–1.27, p=0.004), higher Charlson co-morbidity score (1.08, 1.06–1.09, p=0.000), patient admitted to teaching hospital (1.09, 1.04–1.15, p=0.001) and longer stays in the hospital (1.01, 1.01–1.02, p=0.000). Residence in a small metropolitan (0.91, 0.86–0.97, p=0.003) or micropolitan area (0.83, 0.77–0.90, p=0.000), older age (0.99, 0.993–0.997, p=0.000), female sex (0.91, 0.86–0.95, p=0.000), private (0.85, 0.77–0.93, p=0.000) or no insurance (0.70, 0.53–0.93, p=0.015) were associated with lower odds of readmission. Interestingly discharges to rehabilitation had no effect on re-admission (0.67, 0.28–1.6, p=0.381). Conclusions In conclusion patients hospitalized for acute or acute on chronic HFpEF, we found that 21% of patients were readmitted to the hospital within 30 days of discharge. Readmissions were associated with higher mortality and resource utilization. Most readmissions were due to cardiorenal syndrome. Funding Acknowledgement Type of funding source: None

To identify risk-factors for 30-day hospital readmission in systemic sclerosis pulmonary hypertension (SSc-PH) and to compare trends and characteristics of 30-day readmissions in SSc-PH versus non-SSc pulmonary arterial hypertension (non-SSc PAH).In this retrospective study, we identified SSc-PH and non-SSc PAH hospitalizations using ICD-9 codes within the Healthcare Cost and Utilization Project-National Readmission Database. Thirty-day readmission rates were calculated between 2010 and 2015. Characteristics were compared using chi-square, Wilcoxon rank-sum, or two-sample t-tests between (A) SSc-PH patients with versus without readmission and (B) patients with ≥1 readmission with SSc-PH versus non-SSc PAH. Adjusted logistic regression models were generated for readmission in SSc-PH.4,846 of 22,420 (22%) with SSc-PH and 10,573 of 49,254 (21%) with non-SSc PAH had ≥1 30-day readmission. Between 2010-2015, readmission rate decreased in non-SSc PAH (23% to 20%; p0.001) and was unchanged in SSc-PH (23% to 23%; p = 0.77). In SSc-PH, independent predictors of 30-day readmission include male sex, age60, Medicare or Medicaid, higher Charlson/Deyo comorbidity index, and congestive heart failure (CHF). A higher proportion of patients with SSc-PH (vs. non-SSc PAH) died during index hospitalizations (p = 0.001) and readmissions (p0.001). Readmitted patients with SSc-PH (vs. non-SSc PAH) were younger and less often had CHF. In SSc-PH, the most common readmission primary diagnosis was infection, followed by respiratory and heart failure.In SSc-PH, 30-day readmission is frequent, and in-hospital deaths occur at a higher rate compared to those with non-SSc PAH. This study identifies factors that may characterize those with SSc-PH at highest risk for readmission.