Hanson, Kristine

Background: There are conflicting data regarding the impact of obesity on postoperative outcomes following radical cystectomy (RC) and how obesity and malnutrition interact in patients undergoing RC. Objective: To evaluate associations of body mass index (BMI), significant preoperative weight loss, and hypoalbuminemia with 30-day complications and mortality after RC. Methods: Review of the American College of Surgeons National Surgical Quality Improvement Program database identified 2,055 patients who underwent RC (2006-12). Univariate and multivariable logistic regression models were developed to assess associations between hypoalbuminemia (<3.5 g/dL), >10% preoperative weight loss, obesity as characterized by BMI (class I: 30–34.9, II: 35–39.9, III: ≥40 kg/m 2 ), and 30-day complications and mortality. Results: The median BMI of the study cohort was 27.82 kg/m 2 with 22.4% classified as having class I, 7.5% class II, and 4.2% class III obesity, respectively. Hypoalbuminemia and >10% weight loss were present in 16.7% and 3.5%, respectively. Among obese patients, 13.4% had hypoalbuminemia. On multivariable analysis, class I (OR 1.43, p = 0.01), class II (OR 1.92, p < 0.001), and class III (OR 2.32, p < 0.001) obesity and hypoalbuminemia (OR 1.47, p = 0.02) were independently associated with 30-day complications, and class III obesity (OR 2.96, p = 0.02) and hypoalbuminemia (OR 2.33, p = 0.03) were independently associated with 30-day mortality. Conclusion: Increasing class of obesity and hypoalbuminemia were independently associated with increased complications following RC. Hypoalbuminemia and class III obesity were associated with early mortality. This study highlights the fact that malnutrition may coexist in obese patients and underscores the need to identify patients with malnutrition who may be candidates for preoperative nutritional optimization.

Introduction and Objective: Conflicting data exists regarding the impact of body mass index (BMI) on postoperative outcomes following surgery for renal malignancies (RM). Herein, we investigated associations between obesity, hypoalbuminemia, and/or significant weight loss in the preoperative period, and risk complications and mortality within 30 days of radical (RN) or partial nephrectomy (PN). Materials and Methods: Review of the American College of Surgeons National Surgical Quality Improvement Program database identified 8,618 patients treated with PN or RN for RM between 2005 and 2012. Univariate and multivariable logistic regression models were developed to assess associations between hypoalbuminemia (<3.5 g/dl), >10% weight loss within 6 months of surgery, obesity (BMI >30 kg/m 2 ), and 30-day major complications and mortality. Results: Median BMI was 29.2 kg/m 2 with 24.9%, 11.9%, and 8.2% having class I, II, and III obesity, respectively. Weight loss of >10% was observed in 2.6% and 15.4% had preoperative albumin<3.5 g/dl. There were 1,802 complications (20.9%) and 88 deaths within 30 days (1.0%). On multivariable analysis, BMI ≥40 kg/m 2 (OR 1.3, p = 0.04), >10% weight loss (OR 1.9, p < 0.001) and hypoalbuminemia (OR 1.5, p < 0.001) were independently associated with 30-day complications, while only >10% weight loss was independently associated with 30-day mortality (OR 2.4, p = 0.03). Conclusions: Extreme obesity, hypoalbuminemia, and significant weight loss were independently associated with risk of significant complications following PN or RN while only significant preoperative weight loss was associated with early mortality, underscoring the need to further understand the utility of moderating these risk factors in the perioperative period.

OBJECTIVEPatient-reported outcomes have been increasingly mandated by regulators and payers to evaluate hospital and physician performance. The purpose of this study is to delineate the differences in patient-reported experience of hospital care for cranial and spinal operations.METHODSThe authors selected all patients who underwent inpatient, elective cranial or spinal procedures and completed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey at a single, high-volume, tertiary care institution between October 2012 and September 2015. The association of the surgical procedure and diagnosis with various HCAHPS composite measures, calculated across 9 domains using standard top-box methodology, was investigated. Multivariable logistic regression models were fitted for outcomes that were significant with procedure type and diagnosis group on univariate analysis, adjusting for age, sex, case complexity, overall health rating, and education level.RESULTSA total of 1484 patients met criteria and returned an HCAHPS survey. Overall, patients undergoing a cranial procedure gave top-box (most favorable) scores more often in pain management measure (66.3% vs 59.6%, p = 0.01) compared with those undergoing spine surgery. Furthermore, despite better discharge scores (93.1% vs 87.1%, p < 0.001), spinal patients were less likely to report excellent health (7.4% vs 12.7%). Lastly, patients with a primary diagnosis of brain or spinal tumor compared with those with degenerative spinal disease and those with other neurosurgical diagnoses provided top-box scores more often regarding communication with doctors (82.7% vs 76.4% vs 75.2%, p = 0.04), pain management (71.8% vs 60.9% vs 59.1%, p = 0.002), and global rating (90.4% vs 84.0% vs 87.3%, p = 0.02). On multivariable analysis, spinal patients had significantly lower odds of reporting top-box scores in pain management (OR 0.67, 95% CI 0.52–0.85; p = 0.001), staff responsiveness (OR 0.68, 95% CI 0.53–0.87; p = 0.002), and global rating (OR 0.59, 95% CI 0.42–0.82; p = 0.002), and significantly higher odds of top-box scoring in discharge information (OR 2.15, 95% CI 1.45–3.18; p < 0.001) than cranial patients. Similarly, brain tumor cases were associated with significantly higher odds of top-box scoring in communication with doctors (OR 1.46, 95% CI 1.01–2.12; p = 0.04), pain management (OR 1.81, 95% CI 1.29–2.55; p < 0.001), staff responsiveness (OR 1.88, 95% CI 1.33–2.66; p < 0.001), and global rating (OR 2.00, 95% CI 1.26–3.17; p = 0.003) compared with degenerative spine cases.CONCLUSIONSSignificant differences in patient-reported experience with hospital care exist across different cranial and spine surgery patient populations. Overall, spinal patients, particularly those with degenerative spine disease, rated their health and their hospital experience lower relative to cranial patients. Identifying weaker areas of hospital performance in target populations can stimulate quality initiatives that aim to increase the overall hospital score.

Importance: Media reports have questioned the safety of overlapping surgical procedures, and national scrutiny has underscored the necessity of single-center evaluations of its safety; however, sample sizes are likely small. We compared the safety profiles of overlapping and nonoverlapping pediatric procedures at a single children's hospital and discussed methodological considerations of the evaluation. Data and Design: Retrospective analysis of inpatient pediatric surgical procedures (January 2013 to September 2015) at a single pediatric referral center. Overlapping and nonoverlapping procedures were matched in an unbalanced manner (m:n) by procedure. Mixed models adjusting for Vizient-predicted risk, case-mix, and surgeon compared inpatient mortality and length of stay (LOS). Results: Among 315 overlapping procedures, 256 (81.3%) were matched to 645 nonoverlapping procedures. There were 6 deaths in all. The adjusted odds ratio for mortality did not differ significantly between nonoverlapping and overlapping procedures (adjusted odds ratio = 0.94 vs overlapping; 95% CI, 0.02–48.5; P = 0.98). Wide confidence intervals were minimally improved with Bayesian methods (95% CI, 0.07–12.5). Adjusted LOS estimates were not clinically different by overlapping status (0.6% longer for nonoverlapping; 95% CI, 9.7% shorter to 12.2% longer; P = 0.91). Among the 87 overlapping procedures with the greatest overlap (≥60 min or ≥50% of operative duration), there were no deaths. Conclusions: The safety of overlapping and nonoverlapping surgical procedures did not differ at this children's center. These findings may not extrapolate to other centers. LOS or intraoperative measures may be more appropriate than mortality for safety evaluations due to low event rates for mortality.

Background Surgical site infections (SSIs) result in significant patient morbidity following immediate tissue expander breast reconstruction (ITEBR). This study determined a single institution's 30-day SSI rate and benchmarked it against that among national institutions participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Methods Women who underwent ITEBR with/without acellular dermal matrix (ADM) were identified using the ACS-NSQIP database between 2005 and 2011. Patient characteristics associated with the 30-day SSI rate were determined, and differences in rates between our institution and the national database were assessed. Results 12,163 patients underwent ITEBR, including 263 at our institution. SSIs occurred in 416 (3.4%) patients nationwide excluding our institution, with lower rates observed at our institution (1.9%). Nationwide, SSIs were significantly more common in ITEBR patients with ADM (4.5%) compared to non-ADM patients (3.2%, P=0.005), and this trend was observed at our institution (2.1% vs. 1.6%, P=1.00). A multivariable analysis of all institutions identified age ≥50 years (odds ratio [OR], 1.4; confidence interval [CI], 1.1-1.7), body mass index ≥30 kg/m2 vs. <25 kg/m2 (OR, 3.4; CI, 2.6-4.5), and operative time >4.25 hours (OR, 1.9; CI, 1.5-2.4) as risk factors for SSIs. Our institutional SSI rate was lower than the nationwide rate (OR, 0.4; CI, 0.2-1.1), although this difference was not statistically significant (P=0.07). Conclusions The 30-day SSI rate at our institution in patients who underwent ITEBR was lower than the nation. SSIs occurred more frequently in procedures involving ADM both nationally and at our institution.