Background: Restrictive use of episiotomy has been recommended given potential risks of routine use. However, recent trends in episiotomy utilization and disparities in its use have not been examined at the national level in the United States. The present study aimed to characterize trends in episiotomy use and examine factors associated with high utilization. Methods: The National Inpatient Sample database was queried to identify vaginal deliveries between 2005 and 2016. Patients were stratified based on ICD codes specifying episiotomy. Hospitals were classified as low, medium, and high utilization centers based on the annual number of episiotomies per delivery. Multivariable regressions were used to assess factors associated with episiotomy and high utilization centers. Results: Of 32,975,144 vaginal delivery related hospitaJ Women’s Health Dev 2021; 4 (3): 082-094 DOI: 10.26502/fjwhd.2644-28840063 Journal of Women’s Health and Development Volume 4 No 3 – September 2021 83 lizations, 12.9% underwent an episiotomy. Rates of episiotomy decreased from 19.5% in 2005 to 5.3% in 2016 (P<0.001). Episiotomy was associated with younger age (AOR= 0.96, P<0.001), lower Elixhauser Comorbidity Index (AOR= 0.79, P<0.001), Asian race (AOR= 1.81, P<0.001), private insurance (AOR= 1.32, P<0.001), highest income quartile (AOR= 1.15, P<0.001), as well as thirdand fourth-degree perineal lacerations (AOR= 2.10, P<0.001). High utilization centers were more likely to be urban, non-teaching institutions (AOR=3.54, P<0.001) with high-delivery volume (AOR=13.52, P<0.001) and large bed capacity (AOR=1.24, P<0.001). Conclusions: National rates of episiotomy decreased significantly between 2005 and 2016. Several sociodemographic and hospital-level factors were associated with variation in utilization. Further study of targeted interventions through educational programs and quality benchmarks are needed to better define when episiotomy should be used in obstetrics.

Background: Frailty has been increasingly recognized as an important risk factor for vascular procedures. To assess the impact of frailty on clinical outcomes and resource utilization in patients undergoing carotid revascularization using a national cohort. Methods: The 2005-2017 National Inpatient Sample was used to identify patients who underwent carotid endarterectomy (CEA) or carotid stenting (CAS). Patients were classified as frail using diagnosis codes defined by the Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable regression was used to evaluate associations between frailty and inhospital mortality, postoperative stroke, myocardial infarction (MI), hospitalization costs, and length of stay (LOS). Results: Of 1,426,343 patients undergoing carotid revascularization, 59,158 (4.2%) were identified as frail. Among frail patients, 79.4% underwent CEA and 20.6% underwent CAS. Compared to CEA, a greater proportion of patients undergoing CAS were frail (6.0% vs. 3.8%, P < 0.001). Compared to the nonfrail cohort, frail patients had higher rates of mortality (2.2% vs. 0.5%, P < 0.001), postoperative stroke (2.6% vs. 1.0%, P < 0.001), MI (2.2% vs. 0.8%, P < 0.001), and stroke/death (4.4% vs. 1.4%, P < 0.001). After adjustment, frailty was associated with increased odds of mortality (AOR = 1.59, 95% CI: 1.30-1.80, P < 0.001), stroke (AOR = 1.66, 95% CI: 1.38-1.83 P < 0.001), MI (AOR = 1.51, 95% CI: 1.29-1.72, P < 0.001), and stroke/death (AOR = 1.62, 95% CI: 1.45-1.81, P < 0.001). Furthermore, frailty was associated with increased hospitalization costs ( beta = + $5,980, 95% CI: $5,490-$6,470, P < 0.001) and LOS ( beta = + 2.6 days, 95% CI: 2.4-2.8, P < 0.001). Conclusions: Frailty is associated with adverse outcomes and greater resource use for those undergoing carotid revascularization. Risk models should include an assessment of frailty to guide management and improve outcomes for these high-risk patients.

Background: High hospital safety-net burden has been associated with inferior clinical outcomes. We aimed to characterize the association of safety-net burden with outcomes in a national cohort of patients undergoing carotid interventions. Methods: The 2010-2017 Nationwide Readmissions Database was used to identify adults undergoing carotid endarterectomy and carotid artery stenting. Hospitals were classified as low (LBH), medium, or high safety-net burden (HBH) based on the proportion of uninsured or Medicaid patients. Multivariable models were developed to evaluate associations between HBH and outcomes. Results: Of an estimated 540,558 hospitalizations for a carotid intervention, 28.5% were at HBH. Patients treated at HBH were more likely to be admitted non-electively (28.7% vs 20.2%, P < .001), have symptomatic presentation (11.0% vs 7.7%, P < .001), and undergo carotid artery stenting (18.7% vs 8.9%, P < .001). After adjustment, HBH remained associated with increased odds of postoperative stroke (AOR 1.19, P = .023, Ref = LBH), non-home discharge (AOR 1.10, P = .026), 30-day readmissions (AOR 1.14, P < .001), and 31-90-day readmissions (AOR 1.13, P < .001), but not in-hospital mortality (AOR 1.18, P = .27). HBH was linked to increased hospitalization costs (beta + $2,169, P = .016). Conclusion: HBH was associated with postoperative stroke, non-home discharge, readmissions, and increased hospitalization costs after carotid revascularization. Further studies are warranted to alleviate healthcare inequality and improve outcomes at safety-net hospitals. (C) 2021 Elsevier Inc. All rights reserved.

Many factors affect access to immediate breast reconstruction (IR) after mastectomy. The present study was performed to assess trends, outcomes, and predictors of IR techniques using a nationally representative cohort. The 2009–2014 National Inpatient Sample (NIS) was used to identify adult women who underwent inpatient mastectomy with IR. Patients were compared by type of reconstruction: implant-based IR versus autologous reconstruction (AR). AR was classified as a microsurgical or pedicled flap procedure. Incidence, outcomes, and predictors were assessed using Chi squared univariate tests and multivariable logistic regression analyses. Of 194,073 women who underwent IR, 136,668 (70.4%) received implant-based IR and 57,405 (29.6%) received AR. Of those who underwent AR procedures, 31,336 (54.6%) received microsurgical flaps and 26,680 (46.5%) received pedicled flaps. Utilization of deep inferior epigastric perforator (DIEP) flaps increased significantly (28.6–42.5% of AR, P < 0.001). Predictors of AR were Black race [adjusted odds ratio (AOR) = 1.46, P < 0.001], lower Elixhauser Comorbidity Index (AOR = 1.25, P < 0.001), private insurance (AOR = 1.07, P = 0.030), body mass index (BMI) ≥ 30 kg/m2 (AOR = 1.38, P < 0.001), urban teaching hospital designation (AOR = 1.77, P < 0.001), and high hospital volume (AOR = 3.11, P < 0.001). Similar factors were associated with the use of microsurgical flaps. AR and microsurgical flaps were associated with higher rates of acute inpatient complications, resource utilization and length of stay (LOS) compared with implant-based IR and pedicled flaps, respectively. Implant-based IR remains the most common type of IR, although rates of microsurgical AR are on the rise. Follow-up of complications, costs, and quality-of-life measures may show that AR provides long-term high-value care despite upfront morbidity, cost, and use of hospital resources.