BACKGROUND:The COVID-19 Pandemic challenged the healthcare system worldwide, but its effect on outcomes of cardiac arrest (CA) and extracorporeal membrane oxygenation (ECMO) use are understudied. We examined trends in CA, ECMO use and survival, and evaluated the impact of receiving care during the COVID-19 Pandemic on outcomes following CA. We also evaluated the impact of COVID-19 infection on outcomes following CA. METHODS:Adults with out-of-hospital (OHCA) or in-hospital cardiac arrest (IHCA) were identified in the 2016-2020 National Inpatient Sample. For primary analysis, CA patients without COVID-19 were divided into Pre-Pandemic and Pandemic time-periods. For secondary analysis, CA patients treated during the Pandemic time-period were divided by COVID-19 infection status. Generalized linear models were used to evaluate associations between Pandemic time-period or COVID-19 infection with in-hospital mortality. RESULTS:Of 1,320,020 non-COVID-19 CA patients, 19.1% were managed during the Pandemic. From 2016-2019, CA incidence increased from 696 to 771 per 100,000 hospitalizations, and disproportionately increased to 1,023 per 100,000 hospitalizations by the end of 2020. Mortality for IHCA was stable prior to the Pandemic, but increased from 67.4% to 75.4% by the end of 2020, while mortality for OHCA was stable. ECMO use increased from 2016 to 2019 for OHCA and IHCA, declined during the second quarter of 2020, and recovered to pre-Pandemic levels by the end of 2020. After risk-adjustment, care during the Pandemic was associated with 1.2-fold greater odds of mortality after CA for non-COVID-19 patients. Among 277,975 patients experiencing CA during the Pandemic, 19.6% had concomitant COVID-19 infection. After risk-adjustment, COVID-19 infection was associated with 3.9-fold greater odds of mortality after CA. CONCLUSION:CA incidence and mortality increased during the COVID-19 Pandemic, while ECMO use declined, emphasizing the need to improve care of CA and ECMO patients. COVID-19 patients with CA had dismal outcomes, suggesting no role for ECMO in this population.

Despite advancements in cardiogenic shock (CS) management, mortality remains high. While hospital volume has been linked to reduced mortality across myriad complex procedures, the cross-volume effects of mechanical circulatory support (MCS) and cardiac catheterization laboratory (CCL) procedures on CS patients not receiving these interventions remain unexplored. Using the 2016 to 2022 Nationwide Readmissions Database, we analyzed nonelective adult CS admissions at MCS- and CCL-capable hospitals. Hospitals were stratified into quartiles by annual volumes of MCS (intra-aortic balloon pump, percutaneous ventricular assist device, extracorporeal membrane oxygenation) and CCL procedures (coronary angiography, percutaneous coronary intervention), with the top quartile classified as high-volume (HVH-MCS or HVHCCL). Multivariable logistic and linear regression models were constructed to evaluate the independent association of high-volume status with mortality, complications, and resource utilization. Among 130,822 CS hospitalizations, 48.2% were treated at HVH-MCS and 46.1% at HVHCCL. Unadjusted mortality was lower at HVH-MCS (24.8% vs 30.7%, p <0.001) and HVHCCL (26.6% vs 29.0%, p <0.001). Following adjustment, HVH-MCS remained associated with reduced mortality (Adjusted odds ratio [AOR] 0.87, 95% confidence interval [CI] 0.82 to 0.93), while HVHCCL showed no significant benefit (p = 0.10). HVH-MCS also had lower respiratory (AOR 0.82, 95% CI 0.78 to 0.86) and infectious (AOR 0.85, 95% CI 0.80 to 0.90) complications, but longer hospital stays (β +1.75 days, 95% CI 1.48 to 2.01) and higher costs (+$8,600, 95% CI 7,100 to 10,100). Increasing MCS volume appears independently correlated with improved CS outcomes, highlighting the cross-volume effect of institutional expertise. Contrastingly, CCL volume was not associated with in-hospital mortality, supporting centralization of CS care at high-volume MCS centers.

BACKGROUND:The American Heart Association has advocated for regionalized systems of care for out-of-hospital cardiac arrest (OHCA), emphasizing admission to specialized centers with onsite coronary angiography. However, national data evaluating outcomes of OHCA admission to such centers remain limited. METHODS:Using the 2021 National Inpatient Sample, we identified all direct OHCA hospitalizations across US facilities. Hospitals were categorized as angio-capable if they performed ≥1 coronary angiography in 2021 (others: angio-incapable). The primary outcome was in-hospital mortality. Mixed-effects modeling quantified interhospital variation in mortality. Multivariable logistic regression modeling compared mortality between groups. RESULTS:Of 251 260 OHCA hospitalizations across 2867 centers, 92.6% occurred at angio-capable hospitals and 7.4% at angio-incapable facilities. Patients at angio-capable centers were younger, more frequently male, and had higher rates of ST-segment-elevation myocardial infarction, non-ST-segment-elevation myocardial infarction, cardiogenic shock, and shockable rhythms. Crude mortality was higher at angio-incapable centers than at angio-capable facilities (83.0 versus 67.7%, P<0.001). After adjustment for patient characteristics, hospital-level factors accounted for 13.5% of mortality variation. Admission to angio-incapable centers was associated with 60% greater odds of death (adjusted odds ratio, 1.60 [95% CI, 1.42-1.80]). Marginal effects analysis demonstrated stepwise reduction in predicted mortality rate, from 87.0% (95% CI, 85.5-88.5) at rural angio-incapable centers to 67.3% (95% CI, 66.7-67.9) at urban angio-capable centers. CONCLUSIONS:Admission to hospitals without coronary angiography is associated with higher mortality following OHCA, with the greatest risk observed in rural settings. These findings support regionalized systems of postarrest care and the role of coronary angiography-capable centers as resuscitation hubs.

BACKGROUND:The adoption of robotic-assisted colectomy (RAC) remains limited due to high costs. There is a paucity of data regarding the impact of institutional robotic experience on costs in patients undergoing RAC for colorectal cancer. METHODS:All adult patients undergoing RAC for colorectal cancer were identified using the 2016-2020 Nationwide Readmissions Database. A multivariable regression to model major adverse events (MAE) was developed with the inclusion of institutional robotic surgery volume as restricted cubic splines. The volume corresponding to the inflection point of the spline was used to stratify hospitals into high- (HVH) or low-volume (LVH). We subsequently examined the association of HVH status with costs, length of stay (LOS), MAE, non-home discharge and 30-day unplanned readmission. RESULTS:Among the 39,064 patients undergoing RAC, 65.2% were treated at HVH. Following risk adjustment, RAC at HVH was associated with reduced index hospitalization costs by $2,000 (95%CI $1,500-2,400) and LOS by 0.3 days (95%CI 0.2-0.5 days) as well as decreased odds of MAE (AOR 0.86, 95%CI 0.77-0.96). Both non-home discharge and 30-day unplanned readmission were not associated with hospital volume. In our cross-volume analysis, we found an increase in institutional RAC and overall robotic volumes to be associated with reduced odds of MAE. CONCLUSION:The present study demonstrated higher institutional robotic-assisted operation volume to be associated with reduced MAE and cost in patients undergoing RAC. The findings suggest the potential benefits of increasing expertise and implementing efficient practices in robotic-assisted surgery programs.

BACKGROUND:Although postoperative cardiac arrest is a well-studied complication of cardiac surgery, few guidelines exist regarding timing of surgery in preoperative cardiac arrest (pCA). We examined the association between delayed timing of operation and postoperative outcomes following cardiac surgery in a large cohort of pCA. METHODS:Adults with a diagnosis of pCA undergoing a cardiac operation were identified in the 2016-2020 National Inpatient Sample. Those requiring surgery within 24 hours fo cardiac arrest were excluded. Patients who underwent a cardiac procedure after 5 days of cardiopulmonary resuscitation were classified as Delayed (others: Early). Multivariable regression models were constructed to evaluate associations between delayed timing of surgery with in-hospital mortality, postoperative complications, hospitalization duration, and costs. RESULTS:Of an estimated 9,240 patients meeting study criteria, 4,860 (52.6%) received delayed cardiac surgery. Following entropy balancing, delayed surgery was significantly associated with decreased odds of in-hospital mortality (Adjusted Odds Ratio [AOR] 0.75, 95% Confidence Interval [CI] 0.58 - 0.97). However, delayed operation demonstrated greater odds of postoperative thromboembolic (AOR 1.44, 95% CI 1.02 - 2.04), and infectious (AOR 1.65, 95% CI 1.31 - 2.08) complications. Notably, delay did not alter odds of neurologic complication, and was linked to a decrement in per-day costs (β -$2,100, 95% CI -2,600 - -1,700). CONCLUSIONS:While preoperative cardiac arrest remains challenging, the present study demonstrates the safety profile of delaying cardiac operation among patients tolerating at least 24 hours of a delay to surgery. Future studies are needed to elucidate the factors associated with favorable outcomes in this population.

BACKGROUND:Despite advancements in peri-operative care and conflicting evidence regarding the need for preoperative coronary revascularization, the optimal timing of noncardiac surgery (NCS) following cardiac operations remains unclear. OBJECTIVES:The purpose of this study was to evaluate the effect of time interval between cardiac surgery and NCS on peri-operative risk of major adverse events (MAEs). METHODS:Adults undergoing elective CABG, valve repair or replacement, or combined procedures were identified in the 2016 to 2020 Nationwide Readmissions Database, with subsequent admission for NCS analyzed. The time interval in between NCS and index cardiac operations was modeled using restricted cubic splines, and clinical outcome differences were evaluated across various NCS risk and urgency categories. RESULTS:Of 1,335,175 patients undergoing cardiac surgery, 20,253 (1.5%) required a subsequent NCS. On risk-adjusted examination of MAE rates as a function of time delay after cardiac surgery, an inflection point was noted at 100 days postoperatively. Based on this threshold, 47.9% of patients who had NCS within 100 days were considered early while others were grouped as late. Late NCS was associated with significantly lower odds of MAE (adjusted OR: 0.69; 95% CI: 0.62-0.76), and in-hospital mortality (adjusted OR: 0.66; 95% CI: 0.46-0.96), as compared to early NCS. This relationship persisted across all cardiac surgical subgroups and whether subsequent NCS was elective. Additionally, nonelective procedures classically categorized as low risk in the general population, exhibited comparable rates of MAE to high-risk procedures following early NCS. CONCLUSIONS:When feasible, delaying NCS, particularly beyond 100 days, appears to be associated with a reduction in adverse events, suggesting a potential opportunity for optimization of patient outcomes.

Background Transcatheter aortic valve replacement (TAVR) has transformed the gold standard management of aortic stenosis (AS). Following device approval, surrounding market competition was noted to spur institutional adoption. With the exponential growth of TAVR, it remains unclear how market competition may influence utilization. Objectives The authors sought to evaluate the association of hospital market competition with TAVR utilization in the contemporary period. Methods All adults undergoing TAVR or surgical aortic valve replacement for AS from 2018 to 2021 were tabulated from 7 Healthcare Cost and Utilization Project State Inpatient Databases. Market competition was calculated using the Herfindahl-Hirschman Index, based on a variable radius comprising 75% of total discharges for each institution. Patients treated at hospitals in high market competition areas were grouped as competitive (others: noncompetitive). Results Among 137,734 patients undergoing surgical aortic valve replacement or TAVR, 83,650 (61%) were competitive. The 2 groups were of clinically similar age, sex, and preoperative comorbidity burden. Following risk-adjustment, treatment at a high market competition hospital was associated with significantly greater likelihood of receiving TAVR (adjusted OR [AOR]: 1.68; CI: 1.26-2.23). On age stratification, this effect remained true across age strata, with the greatest effects noted among patients <50 years (AOR: 1.54; CI: 1.12-2.11) and 50 to 60 years (AOR: 1.30; CI: 1.14-1.48). Moreover, care at a high market competition center was linked with similar odds of mortality and composite complications but significantly greater per-patient costs. Conclusions Increasing hospital market competition was linked with increased likelihood of TAVR, particularly among younger populations. Our findings suggest regional competition may be 1 variable that influences clinical practice in the treatment of AS.

BACKGROUND:Limited data exist on trends and differential heart failure (HF) hospitalization rates, particularly when appropriate statistical age standardization is applied. OBJECTIVES:This study aimed to assess temporal trends in age-standardized hospitalization rates and in-hospital mortality for primary HF hospitalizations among younger (<65 years) and older (>64 years) patients, stratified by sex, race/ethnicity, insurance status, and urban/rural hospital location. METHODS:The National Inpatient Sample database was analyzed to identify adults who were hospitalized for HF between 2010 and 2022. HF hospitalization rates and in-hospital mortality trends were then examined across demographic strata. RESULTS:In total, 14,287,733 weighted hospitalizations for HF were identified. Overall, age-standardized HF hospitalizations per 100,000 U.S. population showed a nonsignificant change from 406 in 2010 to 381 in 2014 (P = 0.14), followed by an increase to 447 in 2018 (P = 0.002) and a subsequent decline to 395 in 2022 (P = 0.002). Hospitalization rates declined at rural hospitals but increased among Medicare and Medicaid insurers (P < 0.05). From 2010 to 2022, the <65-year age group experienced increasing hospitalizations (from 124 to 161; average annual percentage change: 2.2 [95% CI: 1.6-2.8]; P < 0.001) in contrast to the >64-year age group (from 1,775 to 1,525; average annual percentage change: -1.2; 95% CI: -2.8 to 0.9). In-hospital mortality for the overall cohort did not improve between 2010 and 2022, and with a significant uptrend observed in 2020 compared with the 2010-2019 period (P = 0.001). CONCLUSIONS:This longitudinal analysis of U.S. hospitalizations from 2010 to 2022 revealed that HF hospitalizations began increasing in 2014, peaked in 2019, and then declined sharply in 2020, a trend that persisted through 2022, with a more pronounced decline among adults aged >64 years. In contrast, HF hospitalizations among adults aged <65 years continued to rise, highlighting a shift in epidemiological landscape in which HF increasingly affects younger populations. In-hospital mortality increased in 2020, changing the trend observed in prior years.

BACKGROUND:Current guidelines recommend 24-hour telemetry monitoring for isolated sternal fractures (ISFs) with electrocardiogram (ECG) abnormalities or troponin elevation. However, a single-center study suggested ISF patients with minor ECG abnormalities (sinus tachycardia/bradycardia, nonspecific arrhythmia/ST-changes, and bundle branch block) may not require 24-hour telemetry monitoring. This study sought to corroborate this, hypothesizing ISF patients would not develop blunt cardiac injury (BCI). MATERIALS & METHODS:A retrospective study was performed at 8 trauma centers (1/2018-8/2020). Patients with ISF (abbreviated injury scale <2 for the head/neck/face/abdomen/extremities) and minor ECG abnormalities or troponin elevations were included. Patients with multiple rib fractures or hemothorax/pneumothorax were excluded. The primary outcome was an echocardiogram confirmed BCI. The secondary outcome was significant BCI defined as cardiogenic shock, dysrhythmia requiring treatment, post-traumatic cardiac structural defects, unexplained hypotension, or cardiac-related procedures. Descriptive statistics were performed. RESULTS:Of 124 ISF patients with minor ECG abnormalities or troponin elevation, 90% were admitted with a mean stay of 35 hours. Echocardiogram was performed for 31.5% of patients, 10 (25.6%) of which had abnormalities. However, no patient had BCI diagnosed on echocardiography. In total, 2 patients (1.6%) had a significant BCI (atrial fibrillation and supraventricular tachycardia at 10 and 82 hours after injury). No patient died. CONCLUSIONS:Following ISF with minor ECG changes or troponin elevation, <2% suffered significant BCI, and none had an echocardiogram diagnosed BCI, despite >30% receiving echocardiogram. These findings challenge the dogma of mandatory observation periods following ISF with associated ECG abnormalities and support the lack of utility for routine echocardiography in these patients.

BACKGROUND:Robotic approaches have been increasingly utilized for cardiothoracic operations, though concerns regarding costs remain. We evaluated short-term outcomes and costs of robotic-assisted and conventional mitral valve repair (MV-repair), hypothesizing that cost differences would be mitigated at high-volume programs. METHODS:Adults undergoing elective MV-repair from 2016 to 2020 were identified in the Nationwide Readmissions Database. Patients with rheumatic heart disease, mitral stenosis, and those undergoing concomitant operations were excluded. Generalized linear models were utilized to evaluate the association between approach and in-hospital mortality, complications, length of stay, costs, and 90-day readmissions. Annual institutional MV-repair volume was modeled using restricted cubic splines, and cost differences subsequently evaluated by volume tertile. RESULTS:Of 40,738 patients, 9.8% underwent robotic-assisted MV-repair. Risk-adjusted outcomes including mortality, stroke, reoperation, respiratory complications, postoperative infection, and readmission were comparable between the 2 groups, while those undergoing robotic-assisted MV-repair had lower rates of nonhome discharge. The median cost of robotic-assisted MV-repair was greater than conventional surgery ($46,800 vs $38,500, P < .001). Despite a 1.3-day decrement (95% CI, 1.1-1.6) in length of stay, robotic-assisted MV-repair was associated with greater risk-adjusted costs by $10,500 (95% CI, $5800-$15,200). Programs in the highest volume tertile exhibited comparable costs for robotic-assisted and conventional MV-repair (cost difference, $5900; 95% CI, -$1200 to $12,200; P > .05). CONCLUSIONS:Robotic-assisted MV-repair had comparable short-term outcomes relative to conventional surgery. Despite increased costs of robotic-assisted MV-repair overall, high-volume programs had similar risk-adjusted costs by approach. These findings support the designation and performance of robotic MV-repair at centers of excellence in the United States.

BackgroundExpedited discharge following esophagectomy is controversial due to concerns for higher readmissions and financial burden. The present study aimed to evaluate the association of expedited discharge with hospitalization costs and unplanned readmissions following esophagectomy for malignant lesions.MethodsAdults undergoing elective esophagectomy for cancer were identified in the 2014-2019 Nationwide Readmissions Database. Patients discharged by postoperative day 7 were considered Expedited and others as Routine. Patients who did not survive to discharge or had major perioperative complications were excluded. Multivariable regression models were constructed to assess association of expedited discharge with index hospitalization costs as well as 30- and 90-day non-elective readmissions.ResultsOf 9,886 patients who met study criteria, 34.6% comprised the Expedited cohort. After adjustment, female sex (adjusted odds ratio [AOR] 0.71, p = 0.001) and increasing Elixhauser Comorbidity Index (AOR 0.88/point, p<0.001) were associated with lower odds of expedited discharge, while laparoscopic (AOR 1.63, p<0.001, Ref: open) and robotic (AOR 1.67, p = 0.003, Ref: open) approach were linked to greater likelihood. Patients at centers in the highest-tertile of minimally invasive esophagectomy volume had increased odds of expedited discharge (AOR 1.52, p = 0.025, Ref: lowest-tertile). On multivariable analysis, expedited discharge was independently associated with an $8,300 reduction in hospitalization costs. Notably, expedited discharge was associated with similar odds of 30-day (AOR 1.10, p = 0.40) and 90-day (AOR 0.90, p = 0.70) unplanned readmissions.ConclusionExpedited discharge after esophagectomy was associated with decreased costs and unaltered readmissions. Prospective studies are necessary to robustly evaluate whether expedited discharge is appropriate for select patients undergoing esophagectomy.

Background: While considered standard of care for obesity management, bariatric surgery is uncommon in patients with co-morbid inflammatory bowel disease (IBD). Objectives: The present study aimed to assess the association of IBD with postoperative outcomes and resource use following bariatric surgery. Setting: Academic, university-affiliated; United States. Methods: All elective adult hospitalizations for laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) were identified in the 2016-2019 Nationwide Readmissions Database. Patients were classified based on diagnosis of ulcerative colitis (UC) or Crohn's disease (CD). Multivariable regression models were developed to evaluate the association of IBD with outcomes of interest. Results: Of an estimated 719,270 eligible patients, 860 and 1214 comprised the UC and CD cohorts, respectively. Compared to non-IBD, UC and CD had a higher Elixhauser comorbidity index (UC: 3.0 +/- 1.4; CD: 3.1 +/- 1.5; non-IBD: 2.7 +/- 1.4, P < .001) and more frequently underwent sleeve gastrectomy (UC: 77.5%; CD: 83.2%; non-IBD: 68.8%, P < .001). All IBD patients survived to discharge. After adjustment, IBD was not associated with significant differences in most clinical outcomes analyzed. UC (adjusted odds ratio: 2.86; 95% confidence interval: 1.14-7.13) and CD (adjusted odds ratio: 4.40; 95% confidence interval: 2.20-8.80) were associated with increased odds of gastric outlet obstruction after RYGB but not sleeve gastrectomy. CD, but not UC, was linked to significantly higher odds of small bowel obstruction following RYGB (adjusted odds ratio: 4.50; 95% confidence interval: 1.76-11.49). There was no difference in index LOS, hospitalization costs, or odds of 30-day readmission based on IBD. Conclusions: Patients with obesity and IBD faced low rates of adverse outcomes following bariatric surgery. There is an increased risk of gastrointestinal obstruction for patients with IBD undergoing RYGB. Given its safety profile, bariatric surgery can be utilized as a weight loss intervention for the growing proportion of patients with obesity and co-morbid IBD.

BACKGROUND:The optimal timing of noncardiac surgery (NCS) following transcatheter aortic valve replacement (TAVR) for aortic stenosis has not been elucidated by current national guidelines. OBJECTIVES:The aim of this study was to evaluate the effect of the time interval between TAVR and NCS (Δt) on the perioperative risk of major adverse events (MAEs). METHODS:All adult admissions for isolated TAVR for aortic stenosis were identified in the 2016 to 2020 Nationwide Readmissions Database. Patients who received NCS on subsequent admission were included for analysis and grouped by Δt as follows: ≤30, 31 to 60, 61 to 90, and >90 days. Multivariable regression models were constructed to examine the association of Δt with ensuing outcomes. RESULTS:Of 3,098 patients (median age = 79 years, 41.6% female), 19.1% underwent NCS at ≤30 days, 22.9% at 31 to 60 days, 16.7% at 61 to 90 days, and 41.3% at >90 days. After adjustment, the odds of MAEs were similar for operations performed at ≤30 days (adjusted OR [AOR]: 1.05; 95% CI: 0.74-1.50), 31 to 60 days (AOR: 0.97; 95% CI: 0.71-1.31), and 61 to 90 days (AOR: 0.95; 95% CI: 0.67-1.34), with those at >90 days as reference. When examining the average marginal effect of the interval to surgery, risk-adjusted MAE rates were statistically similar across Δt groups for elective status and NCS risk category combinations. CONCLUSIONS:NCS within 30, 31 to 60, or 61 to 90 days after TAVR was not associated with increased odds of MAEs compared with operations after 90 days irrespective of NCS risk category or elective status. Our findings suggest that the interval between NCS and TAVR may not be an accurate predictor of MAE risk in this population.

Background: While the impact of socioeconomic status (SES) on surgical outcomes has been examined in limited series, it remains a significant determinant of healthcare outcomes at the national level. Therefore, the current study aims to determine SES disparities at three time-points: hospital accessibility, in-hospital outcomes, and post-discharge consequences. Methods: The Nationwide Readmissions Database 2010-2018 was used to isolate major elective operations. SES was assigned using previously coded median income quartiles as defined by patient zip-code, with low SES de-fined as the lowest quartile and high SES as the highest. Results: Of an estimated 4,816,837 patients undergoing major elective operations, 1,037,689 (21.3 %) were cate-gorized as low SES and 1,288,618 (26.5 %) as high. On univariate analysis and compared to those of low SES, high SES patients were more frequently treated at high-volume centers (70.9 vs 55.6 %, p < 0.001), had lower rates of in-hospital complications (24.0 vs 29.0 %, p < 0.001) and mortality (0.4 vs 0.9 %, p < 0.001) as well as less fre-quent urgent readmissions at 30-(5.7 vs 7.1 %, p < 0.001) and 90-day timepoints (9.4 vs 10.7 %, p < 0.001). On multivariable analysis, high SES patients had higher odds of treatment at high-volume centers (Odds: 1.87, 95 % CI: 1.71-2.06), and lower odds of perioperative complications (Odds: 0.98, 95 % CI: 0.96-0.99), mortality (Odds: 0.70, 95 % CI: 0.65-0.75), and urgent readmissions at 90-days (Odds: 0.95, 95 % CI: 0.92-0.98). Conclusion: This study fills a much-needed gap in the current literature by establishing that all of the aforemen-tioned timepoints include significant disadvantages for those of low socioeconomic status. Therefore, a multidis-ciplinary approach may be required for intervention to improve equity for surgical patients.(c) 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Although groin hernia repairs are relatively safe, efforts to identify factors associated with greater morbidity and resource utilization following these operations are warranted. An emphasis on obesity has limited studies from a comprehensive evaluation of the association between body mass index (BMI) and outcomes following groin hernia repair. Thus, we aimed to ascertain the association between BMI class with 30-day outcomes following these operations. The 2014–2020 National Surgical Quality Improvement Program database was queried to identify adults undergoing non-recurrent groin hernia repair. Patient BMI was used to stratify patients into six groups: underweight, normal, overweight, and obesity classes I–III. Association of BMI with major adverse events (MAE), wound complication, and prolonged length of stay (pLOS) as well as 30-day readmission and reoperation were evaluated using multivariable regressions. Of the 163,373 adults who underwent groin hernia repair, the majority of patients were considered overweight (44.4

BACKGROUND:Although the use of robotic-assisted surgery continues to expand, the cost-effectiveness of this platform remains unclear. The present study aimed to compare hospitalization costs and clinical outcomes between robotic-assisted surgery and laparoscopic approaches for major abdominal operations. METHODS:All adults receiving minimally invasive gastrectomy, cholecystectomy, colectomy (right, left, transverse, sigmoid), ventral hernia repair, hysterectomy, and abdominoperineal resection were identified in the 2012 to 2019 National Inpatient Sample. Records with concurrent operations were excluded. Multivariable linear and logistic regressions were developed to examine the association of the operative approach with costs, length of stay, and complications. An interaction term between the year and operative approach was used to analyze cost differences over time. RESULTS:Of an estimated 1,124,450 patients, 75.8% had laparoscopic surgery, and 24.2% had robotic-assisted surgery. Compared to laparoscopic, patients with robotic-assisted operations were younger and more commonly privately insured. The average hospitalization cost for laparoscopic cases was $16,000 ± 14,800 and robotic-assisted cases was $18,300 ± 13,900 (P < .001). Regardless of procedure type, all robotic-assisted operations had higher costs compared to laparoscopic operations. Risk-adjusted trend analysis revealed that the discrepancy in costs between laparoscopic and robotic-assisted surgery persisted and widened over time from $1,600 in 2012 to $2,600 in 2019. Compared to laparoscopic procedures, robotic procedures had a 2.2% reduction in complications (9.4 vs 11.6%, P < .001) and a 0.7-day decrement in the length of stay (95% confidence interval -0.8 to -0.7). CONCLUSION:Disparities in costs between robotic and laparoscopic abdominal operations have persisted over time. Given the modest decrement in adverse outcomes, further investigation into the clinical benefits of robotic surgery is warranted to justify its greater costs.

Background: Prior work has linked body mass index (BMI) with postoperative outcomes of ventral hernia repair (VHR), though recent data characterizing this association are limited. This study used a contemporary national cohort to investigate the association between BMI and VHR outcomes.Methods: Adults & GE; 18 years undergoing isolated, elective, primary VHR were identified using the 2016-2020 American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI. Restricted cubic splines were utilized to ascertain the BMI threshold for significantly increased morbidity. Multivariable models were developed to evaluate the association of BMI with outcomes of interest.Results: Of -89,924 patients, 0.5 % were considered Underweight, 12.9 % Normal Weight, 29.5 % Overweight, 29.1 % Class I, 16.6 % Class II, 9.7 % Class III, and 1.7 % Superobese. After risk adjustment, class I (Adjusted Odds Ratio [AOR] 1.22, 95 % Confidence Interval [95%CI]: 1.06-1.41), class II (AOR 1.42, 95%CI: 1.21-1.66), class III obesity (AOR 1.76, 95%CI: 1.49-2.09) and superobesity (AOR 2.25, 95 % CI: 1.71-2.95) remained associated with increased odds of overall morbidity relative to normal BMI following open, but not laparoscopic, VHR. A BMI of 32 was iden-tified as the threshold for the most significant increase in predicted rate of morbidity. Increasing BMI was linked to a stepwise rise in operative time and postoperative length of stay.Conclusion: BMI & GE; 32 is associated with greater morbidity following open, but not laparoscopic VHR. The rele-vance of BMI may be more pronounced in open VHR and must be considered for stratifying risk, improving out-comes, and optimizing care. Key message: Body mass index (BMI) continues to be a relevant factor in morbidity and resource use for elective open ventral hernia repair (VHR). A BMI of 32 serves as the threshold for significant increase in overall compli-cations following open VHR, though this association is not observed in operations performed laparoscopically. & COPY; 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

ObjectiveTo assess the reliability of 30-day non-elective readmissions as a quality metric for adult cardiac surgery. BackgroundUnplanned readmissions is a quality metric for adult cardiac surgery. However, its reliability in benchmarking hospitals remains under-explored. MethodsAdults undergoing elective isolated coronary artery bypass grafting (CABG), surgical aortic valve replacement/repair (SAVR) or mitral valve replacement/repair (MVR) were tabulated from 2019 Nationwide Readmissions Database. Multi-level regressions were developed to model the likelihood of 30-day unplanned readmissions and major adverse events (MAE). Random intercepts were estimated, and associations between hospital-specific risk-adjusted rates of readmissions and were assessed using the Pearson correlation coefficient (r). ResultsOf an estimated 86 024 patients meeting study criteria across 298 hospitals, 62.6% underwent CABG, 22.5% SAVR and 14.9% MVR. Unadjusted readmission rates following CABG, SAVR and MVR were 8.4%, 9.3% and 11.8%, respectively. Unadjusted MAE rates following CABG, SAVR and MVR were 35.1%, 32.3% and 37.0%, respectively. Following adjustment, interhospital differences accounted for 4.1% of explained variance in readmissions for CABG, 7.6% for SAVR and 10.0% for MVR. There was no association between readmission rates for CABG and SAVR (r=0.10, p=0.09) or SAVR and MVR (r=0.09, p=0.1). A weak association was noted between readmission rates for CABG and MVR (r=0.20, p<0.001). There was no significant association between readmission and MAE for CABG (r=0.06, p=0.2), SAVR (r=0.04, p=0.4) and MVR (r=-0.03, p=0.6). ConclusionOur findings suggest that readmissions following adult cardiac surgery may not be an ideal quality measure as hospital factors do not appear to influence this outcome.

Colon cancer (CC) remains a leading cause of cancer-related mortality worldwide, for which colectomy represents the standard of care. Yet, the impact of delayed resection on survival outcomes remains controversial. We assessed the association between time to surgery and 10-year survival in a national cohort of CC patients. This retrospective cohort study identified all adults who underwent colectomy for Stage I–III CC in the 2004–2020 National Cancer Database. Those who required neoadjuvant therapy or emergent resection < 7 days from diagnosis were excluded. Patients were classified into Early (< 25 days) and Delayed (≥ 25 days) cohorts after an adjusted analysis of the relationship between time to surgery and 10-year survival. Survival at 1-, 5-, and 10-years was assessed via Kaplan–Meier analyses and Cox proportional hazard modeling, adjusting for age, sex, race, income quartile, insurance coverage, Charlson–Deyo comorbidity index, disease stage, location of tumor, receipt of adjuvant chemotherapy, as well as hospital type, location, and case volume. Of 165,991 patients, 84,665 (51

Background Despite the known advantages of minimally invasive surgery (MIS) for diverticular disease, the impact of conversions to open (CtO) colectomy remains understudied. The present study used a nationally representative database to characterize risk factors and outcomes associated with CtO in patients with diverticular disease. Methods All elective adult hospitalizations entailing colectomy for diverticulitis were identified in the 2017–2019 Nationwide Readmissions Database. Annual institutional caseloads of MIS and open colectomy were independently tabulated. Restricted cubic splines were utilized to non-linearly estimate the risk-adjusted association between hospital volumes and CtO. Additional regression models were developed to evaluate the association of CtO with outcomes of interest. Results Of an estimated 110,281 patients with diverticulitis who met study criteria, 39.3% underwent planned open colectomy, 53.3% completed MIS, and 7.4% had a CtO. Following adjustment, an inverse relationship between hospital MIS volume and risk of CtO was observed. In contrast, increasing hospital open volume was positively associated with greater risk of CtO. On multivariable analysis, CtO was associated with lower odds of mortality (AOR 0.3, p = 0.001) when compared to open approach, and similar risk of mortality when compared to completed MIS (AOR 0.7, p = 0.436). Conclusion In the present study, institutional MIS volume exhibited inverse correlation with adjusted rates of CtO, independent of open colectomy volume. CtO was associated with decreased rates of mortality compared to planned open approach but equivalence risk relative to completed MIS. Our findings highlight the importance of MIS experience and suggest that MIS may be safely pursued as the initial surgical approach among diverticulitis patients.