BACKGROUND:The association between social determinants of health and adverse perioperative outcomes is well established across surgical specialties. While treatment at high-volume hospitals has been historically linked to improved survival and outcomes following cardiac surgery, it remains unclear whether these volume-associated benefits extend to socially vulnerable populations. METHODS:The 2016-2022 National Inpatient Sample was queried to identify all adult (≥18 years) hospitalizations that included elective coronary artery bypass grafting and isolated or concomitant valve procedures. We ascertained the presence of social vulnerability using validated International Classification of Diseases, Tenth Revision diagnosis codes. Patients with at least 1 documented social determinant of health risk factor were grouped as vulnerable (others: nonvulnerable). Hospitals in the highest quartile by cumulative center-level cardiac operation volume were categorized as high-volume hospitals. Multivariable regressions were employed to evaluate the association between social determinants of health and outcomes of interest. RESULTS:Of an estimated 957,570 cardiac patients meeting inclusion criteria, 6.2% were defined as vulnerable. Following comprehensive risk adjustment, the vulnerable group demonstrated increased mortality (adjusted odds ratio, 2.20; 95% confidence interval, 1.97-2.45), major complications (adjusted odds ratio, 1.80; 95% confidence interval, 1.72-1.89), and failure to rescue (adjusted odds ratio, 1.67; 95% confidence interval, 1.49-1.87). Vulnerable continued to be associated with increased failure to rescue (adjusted odds ratio, 1.83; 95% confidence interval, 1.58-2.10) at high-volume hospitals. Importantly, the interaction between vulnerable group and treatment at high-volume hospitals was insignificant. CONCLUSION:Social vulnerability remained profoundly associated with increased mortality, major complications, and failure to rescue following major cardiac operations. Treatment at high-quality surgical facilities alone does not sufficiently address these disparities, emphasizing the need for broader systemic efforts.

BACKGROUND:Metabolic and bariatric surgery (MBS) remains the most effective intervention for durable weight loss and improvement of obesity-related comorbidities. However, its association with psychiatric morbidity remains unclear. OBJECTIVES:To evaluate the association between prior MBS status and psychiatric morbidity at a national level and to identify any contributing factors. SETTING:National Inpatient Sample, the largest publicly available all-payer inpatient database in the United States. METHODS:A retrospective cohort analysis was conducted using data from 2016 to 2021. Adult encounters (≥18 years) with documented body masss index (BMI) were included and stratified by prior MBS status. Following entropy balancing to minimize baseline differences, multivariable models were used to evaluate the independent cross-sectional association between prior MBS status and psychiatric morbidity odds. RESULTS:Among 32,879,950 encounters, 831,285 (2.5%) involved patients with prior MBS. After entropy balancing and risk adjustment, prior MBS status was independently associated with increased odds of depression (adjusted odds ratio [AOR], 1.70; 95% confidence interval [CI], 1.68-1.72), bipolar disorder (AOR, 1.52; 95% CI, 1.48-1.56), anxiety (AOR, 1.49; 95% CI, 1.47-1.51), and eating disorders (AOR, 1.34; 95% CI, 1.20-1.51), but not with suicidal ideation and attempt (AOR, 1.00; 95% CI, .95-1.06; P = .99). Within the MBS cohort, lower postoperative BMI was progressively associated with higher odds of psychiatric morbidity (P < .001 for trend). CONCLUSIONS:Prior MBS status is associated with increased odds of psychiatric morbidity, particularly among patients with lower postoperative BMI. While causality cannot be inferred, these findings highlight the need for integrated mental health screening and longitudinal psychiatric support throughout the perioperative continuum.

BACKGROUND:Infections following cardiac surgery carry a significant mortality burden. While traditional factors, including emergency surgery, diabetes, and smoking, have been linked with increased risk of infection following coronary artery bypass grafting, recent evidence highlights nontraditional factors, including social determinants of health. In the present work, we characterized the association of low-income status with perioperative infection risk in a national cohort of coronary artery bypass grafting recipients. METHODS:All elective adult (≥18 years) hospitalization records entailing isolated coronary artery bypass grafting were tabulated from the 2016-2022 Nationwide Readmissions Database. Patients were grouped into income quartiles according to the ZIP code-derived household income. Infections of interest included wound, respiratory, and gastrointestinal infections, among others. Multivariable regression models were developed to determine the association between income and outcomes. RESULTS:Of 543,869 admissions for coronary artery bypass grafting, 134,490 (25.3%) were classified as low income, whereas 95,751 (18.7%) were classified as high income. Low-income patients were younger (67 [60-73] vs 68 [61-74], P < .001), more commonly female (25.9 vs 16.8%, P < .001), and less likely to receive treatment at a metropolitan-teaching hospital (77.4% vs 90.0%, P < .001) relative to high-income patients. Following doubly robust risk adjustment, low income remained associated with increased risk for sepsis and bacteremia (adjusted odds ratio, 1.55; 95% confidence interval, 1.36-1.77), wound (adjusted odds ratio, 1.52; 95% confidence interval, 1.21-1.90), and gastrointestinal (adjusted odds ratio, 1.50; 95% confidence interval, 1.17-1.92) infections. Moreover, low income was associated with higher odds of mortality (adjusted odds ratio, 1.67; 95% confidence interval, 1.46-1.92). CONCLUSION:Low-income status is associated with increased risk of infection among coronary artery bypass grafting recipients. While income is not a modifiable risk factor, further research should examine underlying mechanisms and identify areas for quality improvements, including better longitudinal access to care.

BackgroundFailure to rescue (FTR), defined as mortality following a major postoperative complication, has emerged as a key quality metric in cardiac surgery. While socioeconomic disparities in surgical outcomes are well-documented, the relationship between socioeconomic status (SES) and FTR remains insufficiently characterized, particularly regarding which SES components most strongly drive this risk.MethodsAll adults experiencing a Society of Thoracic Surgeons-defined major complication following cardiac surgery were identified from the 2016-2022 Nationwide Readmissions Database. Patients were stratified into low-, middle-, and high-SES groups using a composite metric integrating payer status, neighborhood income quartile, and ICD-10-coded social determinants. Multivariable regression models were developed to examine the association between SES and FTR.ResultsOf an estimated 67,982 patients with major complications, 10,793 (15.9%) experienced FTR. FTR rates increased from 16.0% in 2016 to 18.4% in 2022 (nptrend<0.05), while complication incidence correspondingly declined. Following multivariable adjustment, low- and middle-SES were independently associated with increased odds of FTR compared to high-SES (AOR 1.33, 95% CI 1.19-1.48; AOR 1.18, 95% CI 1.07-1.30, respectively). Upon stratification by individual SES factors, the lowest income quartile consistently demonstrated increased FTR risk, whereas Medicaid status was not significantly associated with FTR.DiscussionSocioeconomic status was independently associated with FTR in a dose-dependent manner. The stronger association with neighborhood income rather than insurance status suggests FTR disparities represent a geographically localized phenomenon. Targeted interventions focusing on communities where low-income patients are concentrated may yield greater impact than population-wide strategies.

BackgroundAmong patients undergoing major abdominal surgery (MAS), ∼3% develop cardiac complications (CC) and face poorer prognosis. This study aimed to characterize outcomes and identify factors associated with CC following MAS.MethodsAll elective adult (>17) hospitalizations for MAS (colectomy, esophagectomy, gastrectomy, hepatectomy, nephrectomy, pancreatectomy, splenectomy) were identified in the 2016-2022 National Inpatient Sample, using survey weights to generate nationally representative estimates. The primary outcome of interest was the development of CC (acute myocardial infarction (AMI) and cardiac arrest). We also evaluated patient and institutional factors associated with failure-to-rescue (FTR) following CC. Risk-adjusted analyses with multivariable regressions were used to characterize factors associated with the development of CC. Subgroup analyses were conducted for isolated AMI and cardiac arrest.ResultsOf an estimated 904 270 patients, 1.8% developed CC. Compared to others, CC were older (71 vs 62 years), less commonly female (36.5 vs 52.1%, P < 0.001), and had a higher burden of comorbidities (Elixhauser: 5 vs 3). Following risk-adjustment, older age (adjusted odds ratio (AOR) 1.02, 95% confidence interval (CI) 1.02-1.03) and higher burden of comorbidity (AOR 1.62, 95% CI: 1.59-1.66) were independently associated with CC (P < 0.05). Greater annual institution PCI and MAS caseloads were independently associated with a reduced risk of CC (P < 0.001). Furthermore, CC was associated with greater mortality (AOR 10.53, 95% CI: 8.90-12.46), respiratory complications (AOR 3.53, 95% CI: 3.18-3.91), and higher costs (β +$8,500, 95% CI: 7400-9700). On subgroup analysis, cardiac arrest revealed markedly higher mortality risk (AOR 6.86) than AMI alone (AOR 1.28).DiscussionIn summary, CC was associated with inferior outcomes and higher resource utilization. Furthermore, we found patient and hospital factors to be independently linked with CC risk. These findings highlight an association between institutional MAS and PCI volume and reduced CC risk, warranting further investigation into the role of center-level factors in perioperative cardiac outcomes.

Background Adults with Down syndrome (DS) have a greater likelihood of being diagnosed with congenital heart disease (CHD) and may face unique cardiovascular, respiratory, and immunologic health burdens during hospitalization. While CHD survival has improved in recent decades, national data on hospitalization outcomes of patients diagnosed with DS remain limited. Objectives The present study aimed to evaluate trends in hospital admissions, inpatient management, and perioperative outcomes stratified by the presence of DS among CHD patients. Methods This was a retrospective cohort of the 2016-2022 National Inpatient Sample. All adult (18-64 years) hospitalizations with a diagnosis of congenital heart disease, were tabulated using previously validated International Classification of Diseases diagnosis codes. Our Primary outcome of interest was in-hospital mortality. Secondary endpoints included temporal trends in admissions, utilization of various cardiac procedures, and length of stay. Results Of an estimated 54,410 CHD patients hospitalized, 3,745 (6.9%) had diagnosis of DS. During the study period, annual CHD admissions increased (nptrend<0.05), while the proportion of those with DS remained stable (6.6% to 6.2%, 2016–2022; nptrend=0.23). Patients with DS more commonly presented as having hypothyroidism, dementia, chronic obstructive pulmonary disease (all P<0.05) and less frequently underwent cardiac procedures (7.6 vs 23.2%, P<0.001). Following risk-adjustment, the presence of DS remained independently associated with greater odds of mortality among all hospitalizations (AOR 2.00, 95%CI 1.40–2.88, P<0.001). Conclusions Adults with DS and CHD represent a clinically vulnerable population with higher in-hospital mortality and lower procedural utilization. These findings underscore the need for dedicated care pathways to improve outcomes during medical admissions.

Background Abdominal aortic aneurysm (AAA) size thresholds for elective endovascular aneurysm repair (EVAR) remain primarily based on rupture risk and historical data, with limited validation in the modern endovascular era. In particular, the procedural risk trajectory across the spectrum of aortic diameters and the relevance of sex-specific thresholds remains poorly defined. Methods A retrospective cohort analysis was performed using the 2012–2022 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Targeted EVAR dataset. Adult patients undergoing elective EVAR for asymptomatic, unruptured AAA were included. Restricted cubic spline modeling identified sex-specific aneurysm diameters associated with increased major adverse events (MAE), defined as 30-day mortality or major complications. Patients were stratified by spline-derived diameter thresholds. Risk-adjusted associations between aneurysm size and perioperative outcomes were evaluated using multivariable logistic regression with LASSO-based covariate selection. Results Among 13,626 patients undergoing elective EVAR for asymptomatic, unruptured AAA, 18.1% were female. Female patients underwent repair at smaller median aortic diameters than male patients (5.4 [5.0–5.8] vs 5.5 [5.2–6.0] cm) but demonstrated a higher aortic size index (3.3 [2.9–3.7] vs 2.9 [2.6–3.2] cm/m2). Sex-specific spline analyses identified inflection points for procedural risk at 5.3 cm in males and 5.2 cm in females. Repair at or above these thresholds was associated with higher rates of MAE in males (12.1% vs 9.2%) and females (21.9% vs 16.1%). Among females, above-threshold repair was also associated with higher 30-day mortality (2.4% vs 1.1%), greater transfusion requirement (12.1% vs 6.7%), and longer postoperative LOS (2 [1–3] vs 1 [1–2] days). After risk adjustment, aneurysm diameter at or above the spline-derived threshold remained independently associated with higher odds of MAE and prolonged hospital LOS in both sexes (all P<0.05), with no difference in risk-adjusted 30-day readmission. Conclusions Spline-derived thresholds revealed earlier onset of procedural risk than current guideline cutoffs for both sexes. Incorporating sex-specific, empirically derived risk markers into operative decision-making frameworks may improve timing of elective EVAR and enhance perioperative outcomes.

Background Whole-body computed tomography (WBCT) is frequently used in trauma, though its value in stable patients remains uncertain. We examined WBCT use after motor vehicle collision (MVC) and whether trauma center designation and American College of Surgeons Committee on Trauma (ACS-COT) verification were associated with imaging practices. Methods Using 2018–2021 Trauma Quality Improvement Program (TQIP) data, we identified adults aged 18–65 with blunt MVC who were stable (systolic blood pressure ≥ 100 and Glasgow Coma Scale 15) and received a CT scan. WBCT was defined as head, chest, and abdomen CT within 2 h of admission; selective CT (SCT) covered fewer than all three regions. Temporal trends by state-designated trauma level and ACS-COT verification were assessed using Cuzick's nonparametric test, and multivariable logistic regression identified factors associated with WBCT use. Results Among 288,264 stable MVC patients receiving CT, 78,796 (27.3%) underwent WBCT, and 209,468 (72.7%) SCT. WBCT utilization declined at ACS-verified (31.9 to 30.2%) and non-verified centers (22.0 to 18.4%), and at Level I (29.1 to 27.1%) and Level II (28.5 to 26.9%) facilities (all nptrend <0.001), with consistent declines across Injury Severity Score strata. After adjustment, ACS verification was associated with higher odds of WBCT (AOR 1.96, 95% CI 1.92–2.00), whereas non-profit or government ownership (AOR 0.55, 95% CI 0.54–0.57) was associated with lower odds. Conclusions In stable MVC patients, WBCT utilization declined from 2018 to 2021 across trauma levels and verification strata, while institutional characteristics remained strongly associated with WBCT.

BACKGROUND:Textbook outcome, defined as survival to discharge without complications or prolonged hospitalization, has garnered increasing interest as a surgical quality metric. The present study used a national database to evaluate the utility of textbook outcomes for hospital benchmarking in adult cardiac surgery. METHODS:All elective admissions entailing coronary artery bypass grafting and/or valve operations were identified from the 2016 to 2022 Nationwide Readmissions Database. Textbook outcome was defined as survival to discharge without cardiac arrest, stroke, prolonged ventilation, renal failure, sepsis, pulmonary embolism, reoperation, or length of stay >14 days. Royston-Parmar models were used to evaluate associations between textbook outcome and 180-day mortality and nonelective readmission. Hierarchical logistic regression was used to identify patient and hospital factors associated with the textbook outcome. Centers with risk-adjusted textbook outcome rates in the lowest decile were designated low textbook outcome hospitals. RESULTS:Among 963,775 patients, 86.0% achieved a textbook outcome. Prolonged hospitalization (58.6%) was the most common reason for a non-textbook outcome. After risk adjustment, textbook outcome patients demonstrated significantly reduced 180-day mortality (hazard ratio, 0.37; 95% confidence interval, 0.33-0.41) and nonelective readmission (hazard ratio, 0.66; 95% confidence interval, 0.65-0.68). Approximately 8.5% of the variation in textbook outcome was attributable to interhospital differences. Low textbook outcome hospitals had lower annual operative volume (median, 107 vs 137 cases/year; P < .001) and were less often teaching hospitals (73.6% vs 79.9%; P = .011). CONCLUSION:This work demonstrates that the textbook outcome quality metric captures clinically meaningful differences in survival and readmissions following elective cardiac surgery. There was substantial center-level variation in textbook outcome rates, suggesting its utility for hospital benchmarking.

Periprosthetic joint infection (PJI) following total hip arthroplasty (THA) is associated with a 25% 5-year mortality. Synthetic Minority Oversampling Technique (SMOTE) is a novel machine learning technique used in other surgical specialties to better predict outcomes, but has never been utilized in the field of orthopedics. This is the first study utilizing machine learning (ML) and SMOTE to predict the greatest risk factors for mortality following revision THA for PJI. This retrospective study utilized the Nationwide Readmissions Database to identify adult patients undergoing revision THA for PJI. Model performance was assessed using AUROC, Brier score, and F1 score, with SHapley Additive exPlanation (SHAP) analysis identifying key predictors. Among 19,099 patients undergoing revision THA for PJI, there was a 0.8% mortality rate. Logistic regression (AUROC 0.855) and gradient boosting (AUROC 0.862) outperformed random forest (AUROC 0.765), with gradient boosting demonstrating the highest F1 score (0.257). Following the application SMOTE, all models demonstrated improved AUROC, model calibration, and enhanced F1. SHAP analysis identified fluid and electrolyte disorders, advancing age, and cardiac arrhythmia as key predictors of mortality. This study is the first in the field of orthopedics to utilize SMOTE and subsequently introduces a novel, streamlined risk score that identifies high-risk patients undergoing revision THA for PJI. Fluid and electrolyte abnormalities were the strongest predictors of mortality. Given the established link between high-dose antibiotic-loaded bone cement spacers and calcium sulfate antibiotic impregnated beads with AKI and subsequent electrolyte disturbances, optimizing electrolyte levels perioperatively may be a mortality-reducing intervention.

Background Skiing and snowboarding are popular winter sports in the United States that attract millions of participants annually. Despite advancements in protective equipment and adoption, contemporary national data on trends, injury patterns, and resource utilization associated with ski and snowboard-related hospitalizations remains limited. Methods Nonelective hospitalizations for ski and snowboard-related injuries were identified using the 2016-2022 National Inpatient Sample. Trends in hospitalization incidence and costs were assessed, alongside patient demographics, hospital characteristics, and injury patterns. Results Of 13,105 cases, 79.5% comprised the Ski cohort, while 20.5% comprised the Snowboard cohort. From 2016 to 2022, the incidence of ski-related hospitalizations increased from 1,235 to 1,905 cases (p=0.37; p=0.03 excluding Covid-19 years), while the incidence of snowboard-related hospitalizations increased from 245 to 455 cases (p=0.13; p=0.09 excluding Covid-19 years). Annual costs rose from $29.4 million to $52.5 million for ski-related hospitalizations (p=0.04), and $3.61 million to $9.20 million for snowboard-related hospitalizations (p=0.07). Compared to snowboarders, skiers were older and were more commonly treated at hospitals in rural regions. Across both cohorts, the census divisions with the highest total inpatient costs were the Mountain division ($176 million) followed by the Pacific division ($63.8 million) and the New England division ($26.2 million). Following risk-adjustment, snowboarders were more likely to sustain a traumatic brain injury (Adjusted Odds Ratio [AOR] 1.36, 95% Confidence Interval [CI] 1.04-1.78) as well as fractures to the humerus (AOR 2.32, 95%Cl 1.48-3.63) and radius/ulna (AOR 2.52, 95%CI 1.56-4.07) in reference to skiers. However, snowboarders were less likely to experience femur (AOR 0.37, 95%CI 0.25-0.54) and tibia/fibula fractures (AOR 0.22, 95%CI 0.16-0.32). Moreover, snowboarders faced shorter length of stay (-0.54 days, 95%CI -0.81-(-0.27)) and reduced hospitalization costs (-$3,500, 95%CI -5,500-(-1,500)) compared to skiers. Conclusions Ski and snowboard-related hospitalizations and associated costs rose from 2016 to 2022. Understanding contemporary trends and injury patterns can help inform targeted prevention. Potential strategies include promoting helmet use, equipment maintenance, and enhanced care in rural regions, all of which may help reduce injury risk and healthcare costs.

BACKGROUND:Despite the introduction of enhanced recovery after surgery pathways, the duration of hospital stay for cardiac operations has not considerably declined. In the present work, we evaluated the association of expedited discharge with a marker of resource use in a national cohort. METHODS:All elective (≥18 years) hospitalizations for isolated coronary artery bypass grafting were tabulated from the 2016-2022 Nationwide Readmissions Database utilizing relevant International Classification of Diseases, 10th Revision codes. Patients were stratified into expedited (≤4 days) or routine (>4 days) discharge based on the median length of stay on exploratory analysis. Mixed regression models were developed to identify the association of expedited discharge with hospitalization costs, length of stay, and 30-day readmissions. RESULTS:Of an estimated 511,472 patients undergoing isolated coronary artery bypass grafting, 42.2% experienced expedited discharge. Compared with others, expedited patients were younger (64 years [interquartile range, 58-70] vs 66 years [interquartile range, 60-77], P < .001), less frequently female (14.9 vs 20.2%, P < .001), and more frequently privately insured (43.4 vs 34.7%, P < .001). Following risk adjustment, expedited status was linked with reduced length of stay (β = -1.83 days; 95% confidence interval, -1.85 to -1.82), hospitalization costs (β = -7,160; 95% confidence interval, -7,280 to -7,050), and 30-day readmissions (adjusted odds ratio, 0.70; 95% confidence interval, 0.67-0.62). Upon further analysis, expedited discharge status was associated with greater freedom from readmission, yet there was significant variation in discharge timing. CONCLUSION:Expedited discharge following isolated coronary artery bypass grafting is associated with reduced hospitalization costs, shorter length of stay, and decreased readmission rates, without increased mortality or major complications. These findings support the consideration of safe and cost-effective implementation of recovery protocols in appropriately selected patients.

PURPOSE:Care fragmentation (CF), defined as readmission to a non-index facility, has historically been linked with adverse clinical and financial outcomes for a variety of cardiac procedures. However, its impact on patients undergoing transcatheter aortic valve replacement (TAVR) remains understudied. METHODS:This retrospective study investigated the prevalence and impact of CF on outcomes of patients undergoing TAVR. All adults (≥18 years) undergoing an isolated TAVR procedure, who were readmitted within 90 days, were tabulated using the Nationwide Readmissions Database from 2016 to 2021. A 90-day readmission window was chosen in accordance with prior literature on readmission. Patients treated at a non-index facility were categorized into the CF cohort. Multivariable logistic models were developed to characterize the association of care fragmentation status with perioperative complications and resource utilization; candidate variables were selected using elastic net regularization to minimize variable collinearity. RESULTS:Of an estimated 55,891 patients who were readmitted within 90 days, 37.4% were treated at a non-index facility. While TAVR utilization more than doubled, both the readmission and care fragmentation rates fell during the study period. Following adjustment, CF status was associated with respiratory (AOR [Adjusted Odds Ratio] 1.20, 95% CI [Confidence Interval] 1.11-1.29, p < 0.001), gastrointestinal (AOR 1.21, 95% CI 1.05-1.38, p = 0.008), and infectious complications (AOR 1.17, 95% CI 1.10-1.25, p < 0.001) at readmission. Furthermore, CF was linked with greater risk of non-home discharge (AOR: 1.13 95% CI [1.03-1.25], P = 0.01). CONCLUSIONS:As TAVR utilization continues to expand nationwide, further efforts to enhance care coordination and streamline information sharing are warranted to mitigate the burden of care fragmentation.

BACKGROUND:Safety-net hospitals have demonstrated comparable surgical outcomes to non-safety-net hospitals across various populations, highlighting their potential as regional care centers for diagnosis and treatment of time-sensitive conditions. This study evaluated the impact of safety-net status on clinical and financial outcomes following type A aortic dissection repair. METHODS:The National Inpatient Sample was queried for years 2017 to 2022 to identify adults with a diagnosis of type A aortic dissection. Safety-net hospitals were defined as institutions in the top quartile for the annual proportion of patients with Medicaid or no insurance. Multivariable regression models were used to assess the association of safety-net status with outcomes of interest including in-hospital mortality, perioperative complications, and resource utilization. RESULTS:Of an estimated 25,936 patients with type A aortic dissection undergoing aortic interventions, 7,055 (27.2%) were managed at safety-net hospitals. Compared with non-safety-net hospitals, patients at safety-net hospitals had a similar distribution of age, sex, and Elixhauser Comorbidity Index. After excluding patients who did not receive aortic surgical interventions, the proportion of cases transferred into safety-net hospitals increased from 27.5% to 48.1%. Following adequate risk adjustment, safety-net hospitals did not alter the odds of in-hospital mortality (adjusted odds ratio 1.15, 95% confidence interval 0.72-1.83, reference: non-safety-net hospitals). Notably, higher type A aortic dissection center volume was linked with reduced odds of death, independent of safety-net status (adjusted odds ratio 0.94, 95% confidence interval 0.91-0.97). CONCLUSIONS:Our findings suggest that safety-net hospitals yield comparable perioperative outcomes to non-safety-net hospitals in management of type A aortic dissection outcomes. Future studies are warranted to further investigate the impact of safety-net status on long-term outcomes, as well as rates of readmission and reoperation.

INTRODUCTION:Despite advancements in risk stratification and surgical management, acute type A aortic dissection (TAAD) carries high early mortality and requires emergent surgical repair. While regionalization of care to high-volume centers has demonstrated superior outcomes, interfacility transfer introduces treatment delays and risk of patient deterioration during transport. Using a nationally representative cohort, we sought to characterize the independent association between transfer status and clinical outcomes following TAAD repair. METHODS:Adult patients (≥18 years) undergoing emergency TAAD repair were tabulated from the 2017-2022 Nationwide Readmissions Database. Patients were stratified based on transfer status. Entropy balancing was used to adjust for baseline differences between cohorts, and multivariable regression models assessed the association of transfer status with mortality, perioperative complications, length of stay, and hospitalization costs. RESULTS:Of 27,043 patients, 2,131 (7.9%) were transferred. Following doubly robust risk-adjustment, transferred patients had reduced in-hospital mortality (Adjusted Odds Ratio [AOR] 0.77, 95% Confidence Interval [CI] 0.63-0.94), yet increased odds of cardiac (AOR 1.45, 95% CI 1.26-1.67) and infectious complications (AOR 1.57, 95% CI 1.34-1.84). Additionally, transfer patients incurred greater hospitalization costs (β+ $19,740, 95% CI 12,630-26,860) and greater lengths of stay (β + 5.36 days, CI 4.06-6.66). CONCLUSION:Interfacility transfer for TAAD repair was associated with increased complications, longer hospitalizations, and greater resource utilization, though reduced in-hospital mortality. These findings highlight the importance of regionalized aortic care and the need for standardized transfer protocols to optimize outcomes in this high-risk population.

Successful completion of the Fundamentals of Laparoscopic Surgery (FLS) is a prerequisite for the American Board of Surgery Qualifying Exam. Residents preparing for FLS rely on faculty observation for feedback, which can limit frequency and objectivity. In this study, we developed and validated a computer vision-based artificial intelligence (AI) model to autonomously evaluate performance on the laparoscopic peg transfer task. General surgery residents and medical students at an academic medical center were recorded performing the FLS peg transfer task. Videos were independently scored by two adjudicators as beginner, intermediate, or expert based on task duration and perceived technical performance quality. A computer vision pipeline was constructed and trained under five-fold cross-validation to distinguish skill levels using task duration, instrument path length, and peg displacement as input features. Of 132 total recorded videos, 100 were used for analysis while 32 were excluded due to tracking dropout. The model achieved an overall classification accuracy of 84