Citations

AbstractRationale, aims and objectivesDiagnostic uncertainty is often encountered in a medical practice. Patients with ambiguous, uncertain, and undiagnosed problems are frequently referred for second opinions. Comparing referral diagnoses to final diagnoses provides an opportunity to determine how frequently final diagnoses vary and changes the direction of medical care.MethodsA retrospective study was done at a single academic medical center using a sample of 286 patients referred by physician assistants, nurse practitioners, and physicians from primary care practices from January 1, 2009 to December 31, 2010. Patients' referral and final diagnoses were compared and classified into 1 of 3 categories: referral diagnosis and final diagnosis the same, referral diagnosis better defined/refined, and referral diagnosis distinctly different from final diagnosis. Episode costs for the respective categories were calculated for the referral visit and services that occurred at our facility within the first 30 days.ResultsIn 12% (36/286) of cases, referral diagnoses were the same as final diagnoses. Final diagnoses were better defined/refined in 66% (188/286) of cases; but in 21% of cases (62/286), final diagnoses were distinctly different than referral diagnoses. Total costs for cases in category 3 (different final diagnoses) were significantly higher than costs for cases in category 1 (P = .0001) and category 2 (P = <.0001).ConclusionReferrals to advanced specialty care for undifferentiated problems are an essential component of patient care. Without adequate resources to handle undifferentiated diagnoses, a potential unintended consequence is misdiagnoses resulting in treatment delays and complications leading to more costly treatments.

Background: Unplanned readmission following surgery is a quality metric that helps surgeons assess initiatives targeted at improving patient care. We utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to determine the rates, causes, and predictors of unplanned 30-day readmissions after outpatient elective hand and elbow surgery. Methods: The ACS-NSQIP database was queried using hand-and-elbow-specific Current Procedural Terminology (CPT) codes to retrospectively identify patients who had undergone outpatient hand or elbow surgery in 2012 and 2013. Patients who required an unplanned readmission to the hospital within 30 days were compared with those who were not readmitted. Preoperative patient characteristics, intraoperative variables, complications, and mortality were compared between the cohorts. Cox proportional hazard models were used to determine independent associations with 30-day unplanned readmission. Results: A total of 14,106 outpatient hand or elbow surgery procedures were identified between 2012 and 2013, and 169 (1.2%) of them were followed by an unplanned readmission. The leading causes of readmission included postoperative infections (19.5%), pain (4.7%), thromboembolic events (4.1%), and pulmonary complications (3.0%). The causes of approximately 1/3 of the readmissions were missing from the database, and these readmissions were likely unrelated to the principal procedure. Independent predictors of readmission included an age of 70 to 84 years (hazard ratio [HR] = 2.83, 95% confidence interval [CI] = 1.67 to 4.78), smoking (HR = 2.23, 95% CI = 1.57 to 3.18), a lower hematocrit (HR = 2.19, 95% CI = 1.38 to 3.46), renal dialysis (HR = 3.32, 95% CI = 1.60 to 6.91), and an elbow procedure (with or without a hand procedure) (HR = 2.19, 95% CI = 1.57 to 3.04). Conclusions: The prevalence of unplanned readmission following outpatient hand and elbow surgery is low. Several modifiable factors, including preoperative smoking and anemia, are associated with unplanned readmission. These data may be helpful in developing quality-control initiatives to target unplanned readmissions following hand and elbow procedures. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Purpose To determine the association between the number of patients with multiple myeloma (MM) treated annually at a treatment facility (volume) and all-cause mortality (outcome). Methods Using the National Cancer Database, we identified patients diagnosed with MM between 2003 and 2011. We classified the facilities by quartiles (Q; mean patients with MM treated per year): Q1: < 3.6; Q2: 3.6 to 6.1, Q3: 6.1 to 10.3, and Q4: > 10.3. We used random intercepts to account for clustering of patients within facilities and Cox regression to determine the volume-outcome relationship, adjusting for demographic (sex, age, race, ethnicity), socioeconomic (income, education, insurance type), geographic (area of residence, treatment facility location, travel distance), and comorbid (Charlson-Deyo score) factors and year of diagnosis. Results There were 94,722 patients with MM treated at 1,333 facilities. The median age at diagnosis was 67 years, and 54.7% were men. The median annual facility volume was 6.1 patients per year (range, 0.2 to 109.9). The distribution of patients according to facility volume was: Q1: 5.2%, Q2: 12.6%, Q3: 21.9%, and Q4: 60.3%. The unadjusted median overall survival by facility volume was: Q1: 26.9 months, Q2: 29.1 months, Q3: 31.9 months, and Q4: 49.1 months ( P < .001). Multivariable analysis showed that facility volume was independently associated with all-cause mortality. Compared with patients treated at Q4 facilities, patients treated at lower-quartile facilities had a higher risk of death (Q3 hazard ratio [HR], 1.12 [95% CI, 1.08 to 1.16]; Q2 HR, 1.17 [95% CI, 1.12 to 1.21]; Q1 HR, 1.22 [95% CI, 1.17 to 1.28]). Conclusion Patients who were treated for MM at higher-volume facilities had a lower risk of mortality compared with those who were treated at lower-volume facilities.

Abstract Background: Human papillomavirus (HPV) vaccination rates in the United States remain low and lag behind other recommended adolescent vaccines. Studies evaluating the association of geographic and area-level characteristics with HPV vaccination rates provide a valuable resource for public health planning. Method: We used the Rochester Epidemiology Project data linkage system to ascertain HPV vaccination rates between 2010 and 2015 in a 7-county region of southern Minnesota. Geocoded individual patient data were spatially linked to socioeconomic data from the American Community Survey at the census block group level. Bayesian hierarchical logistic regression was used to model incident vaccination rates, adjusting for individual- and area-level sociodemographic characteristics, and geolocation. Geolocation was modeled as an approximated Gaussian field using a Stochastic Partial Differential Equations approach. All models were estimated using Integrated Nested Laplace Approximations. Results: In adjusted models, increasing age and female sex were associated with increased HPV vaccination. Lower socioeconomic status was associated with decreased rates of initiation [adjusted odds ratio (AOR); 95% confidence interval = 0.90 (0.86–0.95)], completion of the second dose [AOR = 0.88 (0.83–0.93)], and completion of the third dose [AOR = 0.85 (0.80–0.92)]. Geographic spatial analysis demonstrated increased odds of vaccination for the eastern region and in the greater Rochester metropolitan area, showing significant spatial variation not explained by individual level characteristics and ACS block group-level data. Conclusions: HPV vaccination rates varied geographically and by individual and geographically indexed sociodemographic characteristics. Impact: Identifying geographic regions with low HPV vaccination rates can help target clinical and community efforts to improve vaccination rates. Cancer Epidemiol Biomarkers Prev; 26(4); 533–40. ©2017 AACR. See all the articles in this CEBP Focus section, “Geospatial Approaches to Cancer Control and Population Sciences.”

Abstract BACKGROUND Patients recovering from decompressive laminectomy without fusion may require assistance with activities of daily living and physical/occupational therapy upon hospital discharge. OBJECTIVE To examine comorbidities and perioperative characteristics of patients undergoing lumbar decompression for associations with discharge status using a multicenter database. METHODS A multicenter database was used for this retrospective cohort analysis. Patients admitted from home with degenerative spine disease for lumbar decompression without fusion were included. Thirty-day outcomes and operative characteristics were compared as a function of patient discharge using chi-square and Wilcoxon Rank Sum tests. Multivariable logistic regression was used to determine factors associated with discharge to a nonhome facility. RESULTS Of the 8627 patients included for analysis, 9.7% were discharged to a nonhome facility. On multivariable analysis, age (85+ vs <65, odds ratio [OR] 13.59), number of levels of decompression (3+ vs 1, OR 1.75), African American race vs Non-Hispanic or Hispanic White (OR 1.87), female vs male gender (OR 1.97), body mass index (BMI) (40+ vs 18.5-24.9, OR 1.74), American Society of Anesthesiologists physical classification status (4 vs 1 or 2, OR 2.35), hypertension (OR 1.29), dependent functional status (OR 3.92), diabetes (OR 1.47), smoking (OR 1.40), hematocrit (<35 vs 35+, OR 1.76), international normalized ratio (≥1.3 vs <1.3, OR 2.32), and operative time (3+ h vs <1 h, OR 5.34) were significantly associated with an increased odds of discharge to nonhome facilities. CONCLUSION Preoperative status and operative course variables can influence discharge disposition in lumbar decompression patients. Identifying specific factors that contribute to a greater likelihood of dismissal to skilled facility or rehabilitation unit can further inform both surgeons and patients during preoperative counseling and disposition planning.

Objectives We aimed to determine the rates of readmission and reoperation for patients undergoing surgery for pelvic organ prolapse (POP). Methods The American College of Surgeons National Surgical Quality Improvement Program Participant User File was used to select all surgeries performed for POP from 2012 through 2014. The cohort was then reviewed for unplanned readmissions and unplanned reoperations within 30 days of POP surgery. Patient and procedural factors associated with readmission or reoperation were compared using χ2 analyses and Student t test. Multivariable logistic regression determined independent risk factors for both readmission and reoperation. Results A total of 23,419 patients underwent surgery for POP. Of these, there were 435 (1.9%) readmissions and 341 (1.5%) reoperations within 30 days. Median numbers of days from index procedure to readmission or reoperation were 9 and 8 days, respectively. Those who were readmitted had higher American Society of Anesthesia (ASA) scores, longer operative times, and longer lengths of stay than those who were not readmitted (all P < 0.001). Patients who underwent unplanned reoperation also had higher ASA scores, longer operative times, and longer lengths of stay than those who did not undergo reoperation (all P < 0.01). The most common reasons for readmission were surgical site infection (SSI) (19.3%) and non-SSI (15.9%). The most common reason for reoperation was urologic (27.6%) such as cystoscopy or stent placement. Conclusions Readmission and reoperation rates are relatively low for patients undergoing surgery for POP. Infection, both SSI and non-SSI, accounted for 35.2% of readmissions. Identification of ASA score of 3 or higher, longer total operating time, and increased length of stay is associated with unplanned readmission and reoperation.

The purpose of this study was to determine the effect of acute nasal obstruction on sleep and breathing in eight normal persons. The subjects were randomized into two groups. One night the subject was studied with the nose open and a second night with the nose obstructed. The electroencephalogram, electrocardiogram, inspiratory effort, nasal and oral airflow, and oxygen saturation were monitored. Sleep proved to be both subjectively and objectively disturbed. The subjects with the nose obstructed awoke more often, had a greater number of changes in sleep stage, had a prolongation of rapid‐eye‐movement (REM) latency, and spent a greater amount of time in stage I non‐REM sleep (light sleep). Acute nasal obstruction caused a statistically significant increase in the number of partial and total obstructive respiratory events (obstructive hypopnea and obstructive apnea). Sleep apnea developed in one subject during this study merely on the basis of acute nasal obstruction.