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End-of-rotation resident transition in care and mortality among hospitalized patients
CLINICAL QUESTION: Are hospitalized patients experiencing an increased mortality risk at the end-rotation resident transition in care and is this association related to the Accreditation Council for Graduate Medical Education (ACGME) 2011 duty-hour regulations?
BACKGROUND: Prior studies of physicians’ transitions in care were associated with potential adverse patient events and outcomes. A higher mortality risk was suggested among patients with a complex hospital course or prolonged length of stay in association to house-staff transitions of care.
SETTING: 10 University-affiliated U.S. Veterans Health Administration hospitals.
SYNOPSIS: 230,701 patient discharges (mean age, 65.6 years; 95.8% male sex; median length of stay, 3 days) were included. The transition group included patients admitted at any time prior to an end-of-rotation who were either discharged or deceased within 7 days of transition. All other discharges were considered controls.
The primary outcome was in-hospital mortality rate; secondary outcomes included 30-day and 90-day mortality and readmission rates. An absolute increase of 1.5% to 1.9% in a unadjusted in-hospitality risk was found. The 30-day and 90-day mortality odds ratios were 1.10 and 1.21, respectively. A possible stronger association was found among interns’ transitions in care and the in-hospital and after-discharge mortality post-ACGME 2011 duty hour regulations. The latter raises questions about the interns’ inexperience and their amount of shift-to-shift handoffs. An adjusted analysis of the readmission rates at 30-day and 90-day was not significantly different between transition vs. control patients.
BOTTOM LINE: Elevated in-hospital mortality was seen among patients admitted to the inpatient medicine service at the end-of-rotation resident transitions in care. The association was stronger after the duty-hour ACGME (2011) regulations.
CITATIONS: Denson JL, Jensen A, Saag HS, et al. Association between end-of-rotation resident transition in care and mortality among hospitalized patients. JAMA. 2016 Dec 6;316(21):2204-13.
Dr. Orjuela is assistant professor of neurology at the University of Colorado School of Medicine, Aurora
CLINICAL QUESTION: Are hospitalized patients experiencing an increased mortality risk at the end-rotation resident transition in care and is this association related to the Accreditation Council for Graduate Medical Education (ACGME) 2011 duty-hour regulations?
BACKGROUND: Prior studies of physicians’ transitions in care were associated with potential adverse patient events and outcomes. A higher mortality risk was suggested among patients with a complex hospital course or prolonged length of stay in association to house-staff transitions of care.
SETTING: 10 University-affiliated U.S. Veterans Health Administration hospitals.
SYNOPSIS: 230,701 patient discharges (mean age, 65.6 years; 95.8% male sex; median length of stay, 3 days) were included. The transition group included patients admitted at any time prior to an end-of-rotation who were either discharged or deceased within 7 days of transition. All other discharges were considered controls.
The primary outcome was in-hospital mortality rate; secondary outcomes included 30-day and 90-day mortality and readmission rates. An absolute increase of 1.5% to 1.9% in a unadjusted in-hospitality risk was found. The 30-day and 90-day mortality odds ratios were 1.10 and 1.21, respectively. A possible stronger association was found among interns’ transitions in care and the in-hospital and after-discharge mortality post-ACGME 2011 duty hour regulations. The latter raises questions about the interns’ inexperience and their amount of shift-to-shift handoffs. An adjusted analysis of the readmission rates at 30-day and 90-day was not significantly different between transition vs. control patients.
BOTTOM LINE: Elevated in-hospital mortality was seen among patients admitted to the inpatient medicine service at the end-of-rotation resident transitions in care. The association was stronger after the duty-hour ACGME (2011) regulations.
CITATIONS: Denson JL, Jensen A, Saag HS, et al. Association between end-of-rotation resident transition in care and mortality among hospitalized patients. JAMA. 2016 Dec 6;316(21):2204-13.
Dr. Orjuela is assistant professor of neurology at the University of Colorado School of Medicine, Aurora
CLINICAL QUESTION: Are hospitalized patients experiencing an increased mortality risk at the end-rotation resident transition in care and is this association related to the Accreditation Council for Graduate Medical Education (ACGME) 2011 duty-hour regulations?
BACKGROUND: Prior studies of physicians’ transitions in care were associated with potential adverse patient events and outcomes. A higher mortality risk was suggested among patients with a complex hospital course or prolonged length of stay in association to house-staff transitions of care.
SETTING: 10 University-affiliated U.S. Veterans Health Administration hospitals.
SYNOPSIS: 230,701 patient discharges (mean age, 65.6 years; 95.8% male sex; median length of stay, 3 days) were included. The transition group included patients admitted at any time prior to an end-of-rotation who were either discharged or deceased within 7 days of transition. All other discharges were considered controls.
The primary outcome was in-hospital mortality rate; secondary outcomes included 30-day and 90-day mortality and readmission rates. An absolute increase of 1.5% to 1.9% in a unadjusted in-hospitality risk was found. The 30-day and 90-day mortality odds ratios were 1.10 and 1.21, respectively. A possible stronger association was found among interns’ transitions in care and the in-hospital and after-discharge mortality post-ACGME 2011 duty hour regulations. The latter raises questions about the interns’ inexperience and their amount of shift-to-shift handoffs. An adjusted analysis of the readmission rates at 30-day and 90-day was not significantly different between transition vs. control patients.
BOTTOM LINE: Elevated in-hospital mortality was seen among patients admitted to the inpatient medicine service at the end-of-rotation resident transitions in care. The association was stronger after the duty-hour ACGME (2011) regulations.
CITATIONS: Denson JL, Jensen A, Saag HS, et al. Association between end-of-rotation resident transition in care and mortality among hospitalized patients. JAMA. 2016 Dec 6;316(21):2204-13.
Dr. Orjuela is assistant professor of neurology at the University of Colorado School of Medicine, Aurora
VIDEO: Indomethacin slashes post-ERCP pancreatitis risk in primary sclerosing cholangitis
CHICAGO – Rectal indomethacin reduced by 90% the risk of post-procedural pancreatitis in patients with primary sclerosing cholangitis.
The anti-inflammatory has already been shown to reduce the risk of acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in a general population, Nikhil Thiruvengadam, MD, said at the annual Digestive Disease Week®. Now, his retrospective study of almost 5,000 patients has shown the drug’s benefit in patients with primary sclerosing cholangitis (PSC), who are at particularly high risk of pancreatitis after the procedure.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
“A prior history of PEP and a difficult initial cannulation were significant risk factors for developing PEP,” he said. “Indomethacin significantly reduced this risk, and our findings suggest that future prospective trials studying pharmacological prophylaxis of PEP – including rectal indomethacin – should be powered to be able detect a difference in PSC patients, and they should be included in such studies.”
In 2016 Dr. Thiruvengadam and his colleagues showed that rectal indomethacin significantly reduced the risk of PEP by about 65% in a diverse group of patients, including those with malignant biliary obstruction (Gastroenterology. 2016;151:288–97). The new study used an expanded patient-cohort but focused on patients with PSC, as they require multiple ERCPs for diagnosis and stenting of strictures and cholangiocarcinoma screening and thus may be more affected by post-procedural pancreatitis.
The study comprised 4,764 patients who underwent ERCP at the University of Pennsylvania from 2007-2015; of these, 200 had PSC. Rectal indomethacin was routinely administered to patients beginning in June 2012. The primary outcome of the study was post-ERCP pancreatitis. The secondary outcome was the severity of post-ERCP pancreatitis.
PEP was about twice as common in the PSC group as in the overall cohort (6.5% vs. 3.8%). Moderate-severe PEP also was twice as common (4% vs. 2%).
Dr. Thiruvengadam broke down the cohort by indication for ERCP. These included PSC as well as liver transplant, choledocholithiasis, benign pancreatic disease, bile leaks, and ampullary adenoma. PSC patients had the highest risk of developing PEP – almost 3 times more than those without the disorder (OR 2.7).
Among PSC patients, age, gender, and total bilirubin were not associated with increased risk. A history of prior PEP increased the risk by 17 times, and a difficult initial cannulation that required a pre-cut sphincterotomy increased it by 15 times.
“Interestingly, dilation of a common bile duct stricture reduced the odds of developing PEP by 81%,” Dr. Thiruvengadam said.
He then examined the impact of rectal indomethacin on the study subjects. Overall, PEP developed in 5% of those who didn’t receive indomethacin and 2% of those who did. In the PSC group, PEP developed in 11% of those who didn’t get indomethacin and less than 1% of those who did.
Indomethacin was particularly effective at preventing moderate-severe PEP, Dr. Thiruvengadam noted. In the overall cohort, moderate-severe PEP developed in 3% of unexposed patients compared to 0.6% of those who received the drug. The difference was more profound in the PSC group: None of those treated with indomethacin developed moderate-severe PEP, which occurred in 9.3% of the unexposed group.
Generally, patients who have previously undergone a sphincterotomy are at lower risk for PEP, Dr. Thiruvengadam said, and this was reflected in the findings for the overall group: PEP developed in 3% of the untreated patients and 0.5% of the treated patients. Post-sphincterotomy patients with PSC, however, were still at an increased risk of PEP. Indomethacin significantly mitigated this – no patient who got the drug developed PEP, compared with 10.5% of those who didn’t get it.
A series of regression analyses confirmed the consistency of these findings. In an unadjusted model, rectal indomethacin reduced the risk of post-ERCP PEP by 91% in patients with PSC. A model that adjusted for common bile duct brushing, type of sedation, and common bile duct dilation found a 90% risk reduction. Another model that controlled for classic risk factors for PEP (age, gender, total bilirubin, history of PEP, pancreatic duct injection and cannulation, and pre-cut sphincterotomy) found a 94% risk reduction.
“We additionally performed a propensity score matched analysis to account for potential unmeasured differences between the two cohorts, and it also confirmed the results found and demonstrated that indomethacin significantly reduced the odds of developing PEP by 89%,” Dr. Thiruvengadam said.
He had no financial conflicts of interest to disclosures.
Digestive Disease Week® is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).
[email protected]
On Twitter @Alz_gal
CHICAGO – Rectal indomethacin reduced by 90% the risk of post-procedural pancreatitis in patients with primary sclerosing cholangitis.
The anti-inflammatory has already been shown to reduce the risk of acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in a general population, Nikhil Thiruvengadam, MD, said at the annual Digestive Disease Week®. Now, his retrospective study of almost 5,000 patients has shown the drug’s benefit in patients with primary sclerosing cholangitis (PSC), who are at particularly high risk of pancreatitis after the procedure.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
“A prior history of PEP and a difficult initial cannulation were significant risk factors for developing PEP,” he said. “Indomethacin significantly reduced this risk, and our findings suggest that future prospective trials studying pharmacological prophylaxis of PEP – including rectal indomethacin – should be powered to be able detect a difference in PSC patients, and they should be included in such studies.”
In 2016 Dr. Thiruvengadam and his colleagues showed that rectal indomethacin significantly reduced the risk of PEP by about 65% in a diverse group of patients, including those with malignant biliary obstruction (Gastroenterology. 2016;151:288–97). The new study used an expanded patient-cohort but focused on patients with PSC, as they require multiple ERCPs for diagnosis and stenting of strictures and cholangiocarcinoma screening and thus may be more affected by post-procedural pancreatitis.
The study comprised 4,764 patients who underwent ERCP at the University of Pennsylvania from 2007-2015; of these, 200 had PSC. Rectal indomethacin was routinely administered to patients beginning in June 2012. The primary outcome of the study was post-ERCP pancreatitis. The secondary outcome was the severity of post-ERCP pancreatitis.
PEP was about twice as common in the PSC group as in the overall cohort (6.5% vs. 3.8%). Moderate-severe PEP also was twice as common (4% vs. 2%).
Dr. Thiruvengadam broke down the cohort by indication for ERCP. These included PSC as well as liver transplant, choledocholithiasis, benign pancreatic disease, bile leaks, and ampullary adenoma. PSC patients had the highest risk of developing PEP – almost 3 times more than those without the disorder (OR 2.7).
Among PSC patients, age, gender, and total bilirubin were not associated with increased risk. A history of prior PEP increased the risk by 17 times, and a difficult initial cannulation that required a pre-cut sphincterotomy increased it by 15 times.
“Interestingly, dilation of a common bile duct stricture reduced the odds of developing PEP by 81%,” Dr. Thiruvengadam said.
He then examined the impact of rectal indomethacin on the study subjects. Overall, PEP developed in 5% of those who didn’t receive indomethacin and 2% of those who did. In the PSC group, PEP developed in 11% of those who didn’t get indomethacin and less than 1% of those who did.
Indomethacin was particularly effective at preventing moderate-severe PEP, Dr. Thiruvengadam noted. In the overall cohort, moderate-severe PEP developed in 3% of unexposed patients compared to 0.6% of those who received the drug. The difference was more profound in the PSC group: None of those treated with indomethacin developed moderate-severe PEP, which occurred in 9.3% of the unexposed group.
Generally, patients who have previously undergone a sphincterotomy are at lower risk for PEP, Dr. Thiruvengadam said, and this was reflected in the findings for the overall group: PEP developed in 3% of the untreated patients and 0.5% of the treated patients. Post-sphincterotomy patients with PSC, however, were still at an increased risk of PEP. Indomethacin significantly mitigated this – no patient who got the drug developed PEP, compared with 10.5% of those who didn’t get it.
A series of regression analyses confirmed the consistency of these findings. In an unadjusted model, rectal indomethacin reduced the risk of post-ERCP PEP by 91% in patients with PSC. A model that adjusted for common bile duct brushing, type of sedation, and common bile duct dilation found a 90% risk reduction. Another model that controlled for classic risk factors for PEP (age, gender, total bilirubin, history of PEP, pancreatic duct injection and cannulation, and pre-cut sphincterotomy) found a 94% risk reduction.
“We additionally performed a propensity score matched analysis to account for potential unmeasured differences between the two cohorts, and it also confirmed the results found and demonstrated that indomethacin significantly reduced the odds of developing PEP by 89%,” Dr. Thiruvengadam said.
He had no financial conflicts of interest to disclosures.
Digestive Disease Week® is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).
[email protected]
On Twitter @Alz_gal
CHICAGO – Rectal indomethacin reduced by 90% the risk of post-procedural pancreatitis in patients with primary sclerosing cholangitis.
The anti-inflammatory has already been shown to reduce the risk of acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in a general population, Nikhil Thiruvengadam, MD, said at the annual Digestive Disease Week®. Now, his retrospective study of almost 5,000 patients has shown the drug’s benefit in patients with primary sclerosing cholangitis (PSC), who are at particularly high risk of pancreatitis after the procedure.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
“A prior history of PEP and a difficult initial cannulation were significant risk factors for developing PEP,” he said. “Indomethacin significantly reduced this risk, and our findings suggest that future prospective trials studying pharmacological prophylaxis of PEP – including rectal indomethacin – should be powered to be able detect a difference in PSC patients, and they should be included in such studies.”
In 2016 Dr. Thiruvengadam and his colleagues showed that rectal indomethacin significantly reduced the risk of PEP by about 65% in a diverse group of patients, including those with malignant biliary obstruction (Gastroenterology. 2016;151:288–97). The new study used an expanded patient-cohort but focused on patients with PSC, as they require multiple ERCPs for diagnosis and stenting of strictures and cholangiocarcinoma screening and thus may be more affected by post-procedural pancreatitis.
The study comprised 4,764 patients who underwent ERCP at the University of Pennsylvania from 2007-2015; of these, 200 had PSC. Rectal indomethacin was routinely administered to patients beginning in June 2012. The primary outcome of the study was post-ERCP pancreatitis. The secondary outcome was the severity of post-ERCP pancreatitis.
PEP was about twice as common in the PSC group as in the overall cohort (6.5% vs. 3.8%). Moderate-severe PEP also was twice as common (4% vs. 2%).
Dr. Thiruvengadam broke down the cohort by indication for ERCP. These included PSC as well as liver transplant, choledocholithiasis, benign pancreatic disease, bile leaks, and ampullary adenoma. PSC patients had the highest risk of developing PEP – almost 3 times more than those without the disorder (OR 2.7).
Among PSC patients, age, gender, and total bilirubin were not associated with increased risk. A history of prior PEP increased the risk by 17 times, and a difficult initial cannulation that required a pre-cut sphincterotomy increased it by 15 times.
“Interestingly, dilation of a common bile duct stricture reduced the odds of developing PEP by 81%,” Dr. Thiruvengadam said.
He then examined the impact of rectal indomethacin on the study subjects. Overall, PEP developed in 5% of those who didn’t receive indomethacin and 2% of those who did. In the PSC group, PEP developed in 11% of those who didn’t get indomethacin and less than 1% of those who did.
Indomethacin was particularly effective at preventing moderate-severe PEP, Dr. Thiruvengadam noted. In the overall cohort, moderate-severe PEP developed in 3% of unexposed patients compared to 0.6% of those who received the drug. The difference was more profound in the PSC group: None of those treated with indomethacin developed moderate-severe PEP, which occurred in 9.3% of the unexposed group.
Generally, patients who have previously undergone a sphincterotomy are at lower risk for PEP, Dr. Thiruvengadam said, and this was reflected in the findings for the overall group: PEP developed in 3% of the untreated patients and 0.5% of the treated patients. Post-sphincterotomy patients with PSC, however, were still at an increased risk of PEP. Indomethacin significantly mitigated this – no patient who got the drug developed PEP, compared with 10.5% of those who didn’t get it.
A series of regression analyses confirmed the consistency of these findings. In an unadjusted model, rectal indomethacin reduced the risk of post-ERCP PEP by 91% in patients with PSC. A model that adjusted for common bile duct brushing, type of sedation, and common bile duct dilation found a 90% risk reduction. Another model that controlled for classic risk factors for PEP (age, gender, total bilirubin, history of PEP, pancreatic duct injection and cannulation, and pre-cut sphincterotomy) found a 94% risk reduction.
“We additionally performed a propensity score matched analysis to account for potential unmeasured differences between the two cohorts, and it also confirmed the results found and demonstrated that indomethacin significantly reduced the odds of developing PEP by 89%,” Dr. Thiruvengadam said.
He had no financial conflicts of interest to disclosures.
Digestive Disease Week® is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).
[email protected]
On Twitter @Alz_gal
AT DDW
Key clinical point:
Major finding: The anti-inflammatory reduced the risk in these patients by 90%.
Data source: A retrospective study of 4,764 patients with PSC who underwent ERCP at a single institution, Disclosures: Dr. Thiruvengadam had no financial disclosures.
Vulnerable patients face higher risk of 30-day postpartum readmission
SAN DIEGO – Vulnerable patients experienced higher 30-day postpartum readmission rates, regardless of site of care, results from a large national analysis demonstrated.
“Although childbirth is the most common indication for inpatient admission in the United States – accounting for up to 4 million inpatient stays per year – national 30-day postpartum readmission rates, reasons for readmissions, and variation in readmission rates according to patient clinical and demographic characteristics on a national scale remain unknown,” Anju Ranjit, MD, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
Dr. Ranjit, a postdoctoral research fellow at Brigham and Women’s Hospital, Boston, and her associates used multivariable logistic regression to compare differences in 30-day readmissions among 499,578 patients treated at hospitals serving a higher proportion of vulnerable patients (safety net hospitals) with the 30-day readmissions among 877,325 patients treated at hospitals serving a higher proportion of nonvulnerable patients (non–safety net hospitals). Models were adjusted for differences in patient demographics, comorbidities, pregnancy risk-status, type of deliveries, and hospital characteristics.
The researchers included 1,374,903 deliveries in the analysis, which were weighted to represent 3,113,047 deliveries nationwide. The national 30-day postpartum readmission rate was 1.4/100 deliveries. The top three reasons for readmission were wound infection (20.8%), infection (7.7%), and hypertension-related complications (6.2%).
Dr. Ranjit reported that in 2013, a total of 724,833 (53.3%) deliveries were to vulnerable patients and the remaining 652,070 (47.4%) to nonvulnerable patients. The rate of 30-day postpartum readmissions were higher among vulnerable patients, compared with their nonvulnerable counterparts (1.52% vs. 1.18%, respectively; adjusted odds ratio, 1.31; confidence interval, 1.26-1.37) and among patients who were treated at hospitals managing a higher proportion of vulnerable patients (1.51% vs. 1.27%; adjusted OR 1.19; CI, 1.12-1.27).*
“Higher readmission rates seen among vulnerable patients across institutions speak to the need to address disparities in perinatal care,” Dr. Ranjit said. “Quality improvement interventions targeted at safety net hospitals, where the majority of vulnerable patients seek care, could be helpful in reducing readmission rates among vulnerable populations.”
She acknowledged certain limitations of study, including the use of administrative data that is subject to coding error and that lacks clinical granularity.
“We were unable to control for patient’s race and region of residence due of lack of information,” she added. “Classification of hospitals into ‘safety net’ and ‘non–safety net’ hospitals was done – based on the proportion of vulnerable patients served, as identified in the national readmissions database – for the purpose of this study only.”
Dr. Ranjit reported having no financial disclosures.
* Correction, 05/08/17: An earlier version of this article incorrectly described the patient populations.
[email protected]
SAN DIEGO – Vulnerable patients experienced higher 30-day postpartum readmission rates, regardless of site of care, results from a large national analysis demonstrated.
“Although childbirth is the most common indication for inpatient admission in the United States – accounting for up to 4 million inpatient stays per year – national 30-day postpartum readmission rates, reasons for readmissions, and variation in readmission rates according to patient clinical and demographic characteristics on a national scale remain unknown,” Anju Ranjit, MD, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
Dr. Ranjit, a postdoctoral research fellow at Brigham and Women’s Hospital, Boston, and her associates used multivariable logistic regression to compare differences in 30-day readmissions among 499,578 patients treated at hospitals serving a higher proportion of vulnerable patients (safety net hospitals) with the 30-day readmissions among 877,325 patients treated at hospitals serving a higher proportion of nonvulnerable patients (non–safety net hospitals). Models were adjusted for differences in patient demographics, comorbidities, pregnancy risk-status, type of deliveries, and hospital characteristics.
The researchers included 1,374,903 deliveries in the analysis, which were weighted to represent 3,113,047 deliveries nationwide. The national 30-day postpartum readmission rate was 1.4/100 deliveries. The top three reasons for readmission were wound infection (20.8%), infection (7.7%), and hypertension-related complications (6.2%).
Dr. Ranjit reported that in 2013, a total of 724,833 (53.3%) deliveries were to vulnerable patients and the remaining 652,070 (47.4%) to nonvulnerable patients. The rate of 30-day postpartum readmissions were higher among vulnerable patients, compared with their nonvulnerable counterparts (1.52% vs. 1.18%, respectively; adjusted odds ratio, 1.31; confidence interval, 1.26-1.37) and among patients who were treated at hospitals managing a higher proportion of vulnerable patients (1.51% vs. 1.27%; adjusted OR 1.19; CI, 1.12-1.27).*
“Higher readmission rates seen among vulnerable patients across institutions speak to the need to address disparities in perinatal care,” Dr. Ranjit said. “Quality improvement interventions targeted at safety net hospitals, where the majority of vulnerable patients seek care, could be helpful in reducing readmission rates among vulnerable populations.”
She acknowledged certain limitations of study, including the use of administrative data that is subject to coding error and that lacks clinical granularity.
“We were unable to control for patient’s race and region of residence due of lack of information,” she added. “Classification of hospitals into ‘safety net’ and ‘non–safety net’ hospitals was done – based on the proportion of vulnerable patients served, as identified in the national readmissions database – for the purpose of this study only.”
Dr. Ranjit reported having no financial disclosures.
* Correction, 05/08/17: An earlier version of this article incorrectly described the patient populations.
[email protected]
SAN DIEGO – Vulnerable patients experienced higher 30-day postpartum readmission rates, regardless of site of care, results from a large national analysis demonstrated.
“Although childbirth is the most common indication for inpatient admission in the United States – accounting for up to 4 million inpatient stays per year – national 30-day postpartum readmission rates, reasons for readmissions, and variation in readmission rates according to patient clinical and demographic characteristics on a national scale remain unknown,” Anju Ranjit, MD, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
Dr. Ranjit, a postdoctoral research fellow at Brigham and Women’s Hospital, Boston, and her associates used multivariable logistic regression to compare differences in 30-day readmissions among 499,578 patients treated at hospitals serving a higher proportion of vulnerable patients (safety net hospitals) with the 30-day readmissions among 877,325 patients treated at hospitals serving a higher proportion of nonvulnerable patients (non–safety net hospitals). Models were adjusted for differences in patient demographics, comorbidities, pregnancy risk-status, type of deliveries, and hospital characteristics.
The researchers included 1,374,903 deliveries in the analysis, which were weighted to represent 3,113,047 deliveries nationwide. The national 30-day postpartum readmission rate was 1.4/100 deliveries. The top three reasons for readmission were wound infection (20.8%), infection (7.7%), and hypertension-related complications (6.2%).
Dr. Ranjit reported that in 2013, a total of 724,833 (53.3%) deliveries were to vulnerable patients and the remaining 652,070 (47.4%) to nonvulnerable patients. The rate of 30-day postpartum readmissions were higher among vulnerable patients, compared with their nonvulnerable counterparts (1.52% vs. 1.18%, respectively; adjusted odds ratio, 1.31; confidence interval, 1.26-1.37) and among patients who were treated at hospitals managing a higher proportion of vulnerable patients (1.51% vs. 1.27%; adjusted OR 1.19; CI, 1.12-1.27).*
“Higher readmission rates seen among vulnerable patients across institutions speak to the need to address disparities in perinatal care,” Dr. Ranjit said. “Quality improvement interventions targeted at safety net hospitals, where the majority of vulnerable patients seek care, could be helpful in reducing readmission rates among vulnerable populations.”
She acknowledged certain limitations of study, including the use of administrative data that is subject to coding error and that lacks clinical granularity.
“We were unable to control for patient’s race and region of residence due of lack of information,” she added. “Classification of hospitals into ‘safety net’ and ‘non–safety net’ hospitals was done – based on the proportion of vulnerable patients served, as identified in the national readmissions database – for the purpose of this study only.”
Dr. Ranjit reported having no financial disclosures.
* Correction, 05/08/17: An earlier version of this article incorrectly described the patient populations.
[email protected]
AT ACOG 2017
Key clinical point:
Major finding: Vulnerable patients and safety net hospitals had higher rates and adjusted odds of readmission within 30 postdischarge days after delivery.
Data source: An analysis of the Nationwide Readmissions Database to identify deliveries during January 2013-October 2013.
Disclosures: Dr. Ranjit reported having no financial disclosures.
ACOG vows continued fight against rollback of women’s health protections
SAN DIEGO – Just days after the House passage of the GOP-backed American Health Care Act and signals that the Trump administration will revisit mandated coverage of contraception, leaders of the American Congress of Obstetricians and Gynecologists promised to continue fighting for coverage of women’s health services.
ACOG leaders said they have been working on advocacy in the Senate for months already, recognizing that a bill to repeal the Affordable Care Act could pass the House this year. The House-passed legislation, which still must pass the Senate, could be particularly detrimental to women’s health care, they said, because it includes a provision that would allow states to seek waivers for coverage of the essential health benefits package, which includes coverage of maternity care and contraceptives.
Before the ACA was enacted, only about 12% of insurance companies offered maternity care coverage and only three of four states required it, according to Thomas M. Gellhaus, MD, the outgoing ACOG president and an ob.gyn. in Iowa City. Because of the ACA requirements, all women now have that coverage. Additionally, the contraception coverage is what reduces maternal mortality, he said. “The fight will go on,” Dr. Gellhaus said. “We will not give up on this.”
ACOG has already been coordinating meetings between ob.gyns. and members of Congress and telephone calls before votes to reinforce the concerns with pending legislation and the impact it would have on women’s health care, Dr. Gellhaus said.
But this advocacy effort is not a partisan endeavor, said Mark DeFrancesco, MD, an ACOG past president and an ob.gyn. in Cheshire, Conn. “We’re going to stay out of politics,” he said. “You do that by making the only litmus test, ‘Is this good for women or not?’ ”
He added, “If you get out there with the ‘real facts’ ... it shouldn’t matter what your politics are or what your party is. It’s on us to explain things in such a way that we avoid rhetoric and we avoid the ideology.”
Dr. Brown, who encouraged ob.gyns. and their patients to reach out to their members of Congress in person in their home districts, said the message is simple: “This is what it means for your mother, this what it means for your sister, this is what it means for your wife, this is what it means for your daughters.”
[email protected]
On Twitter @maryellenny
SAN DIEGO – Just days after the House passage of the GOP-backed American Health Care Act and signals that the Trump administration will revisit mandated coverage of contraception, leaders of the American Congress of Obstetricians and Gynecologists promised to continue fighting for coverage of women’s health services.
ACOG leaders said they have been working on advocacy in the Senate for months already, recognizing that a bill to repeal the Affordable Care Act could pass the House this year. The House-passed legislation, which still must pass the Senate, could be particularly detrimental to women’s health care, they said, because it includes a provision that would allow states to seek waivers for coverage of the essential health benefits package, which includes coverage of maternity care and contraceptives.
Before the ACA was enacted, only about 12% of insurance companies offered maternity care coverage and only three of four states required it, according to Thomas M. Gellhaus, MD, the outgoing ACOG president and an ob.gyn. in Iowa City. Because of the ACA requirements, all women now have that coverage. Additionally, the contraception coverage is what reduces maternal mortality, he said. “The fight will go on,” Dr. Gellhaus said. “We will not give up on this.”
ACOG has already been coordinating meetings between ob.gyns. and members of Congress and telephone calls before votes to reinforce the concerns with pending legislation and the impact it would have on women’s health care, Dr. Gellhaus said.
But this advocacy effort is not a partisan endeavor, said Mark DeFrancesco, MD, an ACOG past president and an ob.gyn. in Cheshire, Conn. “We’re going to stay out of politics,” he said. “You do that by making the only litmus test, ‘Is this good for women or not?’ ”
He added, “If you get out there with the ‘real facts’ ... it shouldn’t matter what your politics are or what your party is. It’s on us to explain things in such a way that we avoid rhetoric and we avoid the ideology.”
Dr. Brown, who encouraged ob.gyns. and their patients to reach out to their members of Congress in person in their home districts, said the message is simple: “This is what it means for your mother, this what it means for your sister, this is what it means for your wife, this is what it means for your daughters.”
[email protected]
On Twitter @maryellenny
SAN DIEGO – Just days after the House passage of the GOP-backed American Health Care Act and signals that the Trump administration will revisit mandated coverage of contraception, leaders of the American Congress of Obstetricians and Gynecologists promised to continue fighting for coverage of women’s health services.
ACOG leaders said they have been working on advocacy in the Senate for months already, recognizing that a bill to repeal the Affordable Care Act could pass the House this year. The House-passed legislation, which still must pass the Senate, could be particularly detrimental to women’s health care, they said, because it includes a provision that would allow states to seek waivers for coverage of the essential health benefits package, which includes coverage of maternity care and contraceptives.
Before the ACA was enacted, only about 12% of insurance companies offered maternity care coverage and only three of four states required it, according to Thomas M. Gellhaus, MD, the outgoing ACOG president and an ob.gyn. in Iowa City. Because of the ACA requirements, all women now have that coverage. Additionally, the contraception coverage is what reduces maternal mortality, he said. “The fight will go on,” Dr. Gellhaus said. “We will not give up on this.”
ACOG has already been coordinating meetings between ob.gyns. and members of Congress and telephone calls before votes to reinforce the concerns with pending legislation and the impact it would have on women’s health care, Dr. Gellhaus said.
But this advocacy effort is not a partisan endeavor, said Mark DeFrancesco, MD, an ACOG past president and an ob.gyn. in Cheshire, Conn. “We’re going to stay out of politics,” he said. “You do that by making the only litmus test, ‘Is this good for women or not?’ ”
He added, “If you get out there with the ‘real facts’ ... it shouldn’t matter what your politics are or what your party is. It’s on us to explain things in such a way that we avoid rhetoric and we avoid the ideology.”
Dr. Brown, who encouraged ob.gyns. and their patients to reach out to their members of Congress in person in their home districts, said the message is simple: “This is what it means for your mother, this what it means for your sister, this is what it means for your wife, this is what it means for your daughters.”
[email protected]
On Twitter @maryellenny
AT ACOG 2017
Choice of lap vs. open SBO surgery still hinges on patient selection
PHILADELPHIA – In surgery for small-bowel obstruction, laparoscopy is more likely to result in bowel injury than is open surgery but with ultimately better outcomes overall. This means that surgeons should proceed with “considerable caution” when performing minimally invasive surgery in the small bowel, researchers at University of Toronto reported during the annual meeting of the American Surgical Association.
In explaining the rationale for the study, Dr. Behman said, “Several studies have shown that over the last several years [that] the utilization of laparoscopic techniques for adhesive small-bowel obstruction has become increasingly common. However, these procedures have some inherent challenges.” Those technical challenges include introducing the trocar into an abdomen filled with distended bowel, trying to manipulate the distended bowel with laparoscopic bowel graspers, and the potentially ischemic bowel wall, he said.
The University of Toronto researchers performed a population-based retrospective cohort study of 8,584 patients in the Ministry of Health Ontario database from 2005 to 2014. The primary outcome was a composite, consisting of bowel repair, including operative billing codes for either via intraoperative enterotomy or suture repair of the intestine, or bowel resection. Secondary outcomes were serious complications and 30-day mortality.
During the study period, the share of SBO procedures performed laparoscopically increased from 4% in 2005 to 14.3% in 2014, Dr. Behman said.
“Patients in the laparoscopic group were slightly younger, had a lower overall comorbidity burden, and tended to be treated at larger hospitals and hospitals without teaching designations,” Dr. Behman said. Specifically, the average age of the 673 patients who had laparoscopy was 63 years vs. 67 years for the 7,911 open-procedure patients. As for comorbidities, 9% and 50% in the laparoscopic group were healthy and low users and high and very high users, respectively, vs. 7% and 57% of the open-procedure group.
The incidence of any bowel intervention was 53.5% in the laparoscopic group vs. 42% in the open group, Dr. Behman said. After a multivariable regression analysis, the researchers determined the following factors raised a patient’s odds of having a bowel intervention: older age; female sex; having had an after-hours procedure; and having had the procedure earlier in the study period. “However, even after [the researchers adjusted] for all of these covariates, the variable in our model that was most significantly associated with a bowel intervention was having had a laparoscopic procedure, with an odds ratio of 1.6,” Dr. Behman said.
When analyzing secondary outcomes, the researchers found that laparoscopy was associated with a lower risk of 30-day mortality (OR, 0.6) and serious complication (OR, 0.8). “So, there does appear to be a direct trade-off with laparoscopy probably having better clinical outcomes, but also being a risk factor for bowel intervention,” Dr. Behman said. So the researchers preformed a secondary analysis that divided the cohort into four subgroups: laparoscopy with and without bowel intervention; and open surgery with and without bowel intervention.
“The next question we wanted to ask was, in patients that are at high risk of a laparoscopic bowel injury, is an open approach or early conversion to open beneficial?” Dr. Behman said. “To put this another way, is it more important to avoid a bowel intervention or to avoid the morbidity associated with an open procedure?”
The secondary analysis confirmed that laparoscopic patients had lower rates of serious complications: in those without bowel intervention, 5% for laparoscopy vs. 10% for open; and in those who had a bowel intervention, 15% for laparoscopy vs. 22% for open. However, those who had an open procedure without a bowel intervention had lower complication rates than did those who had a laparoscopic operation with a bowel intervention, Dr. Behman said, “suggesting that perhaps the bowel intervention is a greater driver of serious complications than having an open procedure.”
These findings can inform patient selection, Dr. Behman added. “In light of the fact that laparoscopic approaches are likely associated with a greater risk of bowel intervention, appropriate caution should accompany these procedures,” he said. “In patients who are at high risk for a bowel intervention, an open approach or early conversion to a laparotomy should be considered.”
In his discussion of the study, Lawrence Diebel, MD, FACS, of Wayne State University, Detroit, asked if the study accounted for timing of surgery, the etiology of laparoscopic-related bowel interventions, and if serosal tears were included as bowel injuries. Dr. Behman said that the study did include timing of surgery in the initial analysis and found it to be a nonfactor. However, the database did not specify the causes for bowel resections or reasons for conversions.
Dr. Behman and Dr. Diebel reported having no financial disclosures
The complete manuscript of this study and its presentation at the American Surgical Association’s 137th Annual Meeting, April 2017, in Philadelphia, is to be published in the Annals of Surgery pending editorial review.
PHILADELPHIA – In surgery for small-bowel obstruction, laparoscopy is more likely to result in bowel injury than is open surgery but with ultimately better outcomes overall. This means that surgeons should proceed with “considerable caution” when performing minimally invasive surgery in the small bowel, researchers at University of Toronto reported during the annual meeting of the American Surgical Association.
In explaining the rationale for the study, Dr. Behman said, “Several studies have shown that over the last several years [that] the utilization of laparoscopic techniques for adhesive small-bowel obstruction has become increasingly common. However, these procedures have some inherent challenges.” Those technical challenges include introducing the trocar into an abdomen filled with distended bowel, trying to manipulate the distended bowel with laparoscopic bowel graspers, and the potentially ischemic bowel wall, he said.
The University of Toronto researchers performed a population-based retrospective cohort study of 8,584 patients in the Ministry of Health Ontario database from 2005 to 2014. The primary outcome was a composite, consisting of bowel repair, including operative billing codes for either via intraoperative enterotomy or suture repair of the intestine, or bowel resection. Secondary outcomes were serious complications and 30-day mortality.
During the study period, the share of SBO procedures performed laparoscopically increased from 4% in 2005 to 14.3% in 2014, Dr. Behman said.
“Patients in the laparoscopic group were slightly younger, had a lower overall comorbidity burden, and tended to be treated at larger hospitals and hospitals without teaching designations,” Dr. Behman said. Specifically, the average age of the 673 patients who had laparoscopy was 63 years vs. 67 years for the 7,911 open-procedure patients. As for comorbidities, 9% and 50% in the laparoscopic group were healthy and low users and high and very high users, respectively, vs. 7% and 57% of the open-procedure group.
The incidence of any bowel intervention was 53.5% in the laparoscopic group vs. 42% in the open group, Dr. Behman said. After a multivariable regression analysis, the researchers determined the following factors raised a patient’s odds of having a bowel intervention: older age; female sex; having had an after-hours procedure; and having had the procedure earlier in the study period. “However, even after [the researchers adjusted] for all of these covariates, the variable in our model that was most significantly associated with a bowel intervention was having had a laparoscopic procedure, with an odds ratio of 1.6,” Dr. Behman said.
When analyzing secondary outcomes, the researchers found that laparoscopy was associated with a lower risk of 30-day mortality (OR, 0.6) and serious complication (OR, 0.8). “So, there does appear to be a direct trade-off with laparoscopy probably having better clinical outcomes, but also being a risk factor for bowel intervention,” Dr. Behman said. So the researchers preformed a secondary analysis that divided the cohort into four subgroups: laparoscopy with and without bowel intervention; and open surgery with and without bowel intervention.
“The next question we wanted to ask was, in patients that are at high risk of a laparoscopic bowel injury, is an open approach or early conversion to open beneficial?” Dr. Behman said. “To put this another way, is it more important to avoid a bowel intervention or to avoid the morbidity associated with an open procedure?”
The secondary analysis confirmed that laparoscopic patients had lower rates of serious complications: in those without bowel intervention, 5% for laparoscopy vs. 10% for open; and in those who had a bowel intervention, 15% for laparoscopy vs. 22% for open. However, those who had an open procedure without a bowel intervention had lower complication rates than did those who had a laparoscopic operation with a bowel intervention, Dr. Behman said, “suggesting that perhaps the bowel intervention is a greater driver of serious complications than having an open procedure.”
These findings can inform patient selection, Dr. Behman added. “In light of the fact that laparoscopic approaches are likely associated with a greater risk of bowel intervention, appropriate caution should accompany these procedures,” he said. “In patients who are at high risk for a bowel intervention, an open approach or early conversion to a laparotomy should be considered.”
In his discussion of the study, Lawrence Diebel, MD, FACS, of Wayne State University, Detroit, asked if the study accounted for timing of surgery, the etiology of laparoscopic-related bowel interventions, and if serosal tears were included as bowel injuries. Dr. Behman said that the study did include timing of surgery in the initial analysis and found it to be a nonfactor. However, the database did not specify the causes for bowel resections or reasons for conversions.
Dr. Behman and Dr. Diebel reported having no financial disclosures
The complete manuscript of this study and its presentation at the American Surgical Association’s 137th Annual Meeting, April 2017, in Philadelphia, is to be published in the Annals of Surgery pending editorial review.
PHILADELPHIA – In surgery for small-bowel obstruction, laparoscopy is more likely to result in bowel injury than is open surgery but with ultimately better outcomes overall. This means that surgeons should proceed with “considerable caution” when performing minimally invasive surgery in the small bowel, researchers at University of Toronto reported during the annual meeting of the American Surgical Association.
In explaining the rationale for the study, Dr. Behman said, “Several studies have shown that over the last several years [that] the utilization of laparoscopic techniques for adhesive small-bowel obstruction has become increasingly common. However, these procedures have some inherent challenges.” Those technical challenges include introducing the trocar into an abdomen filled with distended bowel, trying to manipulate the distended bowel with laparoscopic bowel graspers, and the potentially ischemic bowel wall, he said.
The University of Toronto researchers performed a population-based retrospective cohort study of 8,584 patients in the Ministry of Health Ontario database from 2005 to 2014. The primary outcome was a composite, consisting of bowel repair, including operative billing codes for either via intraoperative enterotomy or suture repair of the intestine, or bowel resection. Secondary outcomes were serious complications and 30-day mortality.
During the study period, the share of SBO procedures performed laparoscopically increased from 4% in 2005 to 14.3% in 2014, Dr. Behman said.
“Patients in the laparoscopic group were slightly younger, had a lower overall comorbidity burden, and tended to be treated at larger hospitals and hospitals without teaching designations,” Dr. Behman said. Specifically, the average age of the 673 patients who had laparoscopy was 63 years vs. 67 years for the 7,911 open-procedure patients. As for comorbidities, 9% and 50% in the laparoscopic group were healthy and low users and high and very high users, respectively, vs. 7% and 57% of the open-procedure group.
The incidence of any bowel intervention was 53.5% in the laparoscopic group vs. 42% in the open group, Dr. Behman said. After a multivariable regression analysis, the researchers determined the following factors raised a patient’s odds of having a bowel intervention: older age; female sex; having had an after-hours procedure; and having had the procedure earlier in the study period. “However, even after [the researchers adjusted] for all of these covariates, the variable in our model that was most significantly associated with a bowel intervention was having had a laparoscopic procedure, with an odds ratio of 1.6,” Dr. Behman said.
When analyzing secondary outcomes, the researchers found that laparoscopy was associated with a lower risk of 30-day mortality (OR, 0.6) and serious complication (OR, 0.8). “So, there does appear to be a direct trade-off with laparoscopy probably having better clinical outcomes, but also being a risk factor for bowel intervention,” Dr. Behman said. So the researchers preformed a secondary analysis that divided the cohort into four subgroups: laparoscopy with and without bowel intervention; and open surgery with and without bowel intervention.
“The next question we wanted to ask was, in patients that are at high risk of a laparoscopic bowel injury, is an open approach or early conversion to open beneficial?” Dr. Behman said. “To put this another way, is it more important to avoid a bowel intervention or to avoid the morbidity associated with an open procedure?”
The secondary analysis confirmed that laparoscopic patients had lower rates of serious complications: in those without bowel intervention, 5% for laparoscopy vs. 10% for open; and in those who had a bowel intervention, 15% for laparoscopy vs. 22% for open. However, those who had an open procedure without a bowel intervention had lower complication rates than did those who had a laparoscopic operation with a bowel intervention, Dr. Behman said, “suggesting that perhaps the bowel intervention is a greater driver of serious complications than having an open procedure.”
These findings can inform patient selection, Dr. Behman added. “In light of the fact that laparoscopic approaches are likely associated with a greater risk of bowel intervention, appropriate caution should accompany these procedures,” he said. “In patients who are at high risk for a bowel intervention, an open approach or early conversion to a laparotomy should be considered.”
In his discussion of the study, Lawrence Diebel, MD, FACS, of Wayne State University, Detroit, asked if the study accounted for timing of surgery, the etiology of laparoscopic-related bowel interventions, and if serosal tears were included as bowel injuries. Dr. Behman said that the study did include timing of surgery in the initial analysis and found it to be a nonfactor. However, the database did not specify the causes for bowel resections or reasons for conversions.
Dr. Behman and Dr. Diebel reported having no financial disclosures
The complete manuscript of this study and its presentation at the American Surgical Association’s 137th Annual Meeting, April 2017, in Philadelphia, is to be published in the Annals of Surgery pending editorial review.
AT THE ASA ANNUAL MEETING
Key clinical point: Laparoscopic surgery for SBO is associated with a greater risk of bowel intervention.
Major finding: The incidence of bowel intervention was 53.5% vs. 43.4% in laparoscopic and open procedures, respectively.
Data source: Review of 8,584 procedures for SBO in the Ministry of Health Ontario database performed from 2005 to 2014.
Disclosures: Dr. Behman and Dr. Diebel reported having no financial disclosures.
Sex-based differences in lung cancer screening intervals suggested
GENEVA – A lung-cancer screening CT interval of once-yearly for men and once every 3 years for women appears to be the optimum schedule for detecting most early-stage lung cancers while minimizing radiation exposure, results of a retrospective study suggest.
Among 96 patients (85 men and 11 women) with lung cancers detected on follow-up screening CT, the mean interval time between initial CT and diagnostic CT was significantly longer among women than among men, at 5.6 vs. 3.6 years (P = .02), reported Mi-Young Kim, MD, a radiologist at Asan Medical Center in Seoul, South Korea.
Men tended to have a higher stage at diagnosis, however. Stage I cancers were diagnosed in 82% of women, but only 49% of men. Tumor size was also larger among men at presentation at a mean of 29.5 mm vs. 15.5 mm, Dr. Kim and her colleagues found.
Current lung cancer screening guidelines vary somewhat, but most recommend annual screening for people aged 55-80 years who have a 30 pack-year or greater smoking history and are current smokers or have quit within the last 15 years.
Prior studies to see whether longer screening intervals were safe have yielded mixed results, possibly because of differences in clinical and radiologic presentation between men and women, Dr. Kim said.
To explore sex differences in lung cancer at the time of diagnosis, she and her colleagues retrospectively reviewed records for 46,766 patients who underwent screening at their center from January 2000 through February 2016, during which time, 282 patients were diagnosed with lung cancer. Of this group, 186 were diagnosed from the initial screening CT scan, and 96 – the cohort included in the study – were diagnosed from subsequent scans.
The authors found that the majority of men (72%) had solid nodules as the primary pathology. In contrast, ground-glass opacities were the most common nodular finding among women, occurring in 45% of the cases. The most common histology among men was adenocarcinoma (42%), followed by squamous-cell carcinoma (35%), small cell lung cancer (18%), and others (5%). All women presented with adenocarcinoma histology.
“Because ground-glass opacity nodule is the most common feature of lung cancer in women, and all cases are adenocarcinoma, the growth rate of cancers might be low,” Dr. Kim said in a statement.
Only 2 of the 11 women in the study were smokers, compared with 74 of the 85 men.
Looking at the operability of lung cancer according to screening intervals, the investigators found that 100% of tumors detected at 1 year in men were operable, compared with 94% of those detected at 2 years, and 55% for those detected at the 3-year interval. In contrast, among women, there were no tumors detected at 1 year, one operable tumor and no inoperable tumors at 2 years, and two operable and no inoperable tumors at 3 years. Beyond 3 years, however, the rate of inoperable tumors at the time of diagnosis was 32% in men and 25% in women.
“We included all patients screened for lung cancer in a 17-year period, but the number of women patients was low and further studies are needed to confirm the sex differences we found,” Dr. Kim acknowledged.
“Only when this is adjusted for – when we compare smokers of the same pack-year history – then we can look at whether women and men do have different rates of appearance of nodules,” he said.
“To me, this is a very interesting suggestion that indeed the biology of the growth of these nodules may be different in men and women, but only if we are sure that the main environmental factor is taken care of.”
The study funding source was not disclosed.
Dr. Kim and Dr. Boffetta reported no relevant disclosures.
GENEVA – A lung-cancer screening CT interval of once-yearly for men and once every 3 years for women appears to be the optimum schedule for detecting most early-stage lung cancers while minimizing radiation exposure, results of a retrospective study suggest.
Among 96 patients (85 men and 11 women) with lung cancers detected on follow-up screening CT, the mean interval time between initial CT and diagnostic CT was significantly longer among women than among men, at 5.6 vs. 3.6 years (P = .02), reported Mi-Young Kim, MD, a radiologist at Asan Medical Center in Seoul, South Korea.
Men tended to have a higher stage at diagnosis, however. Stage I cancers were diagnosed in 82% of women, but only 49% of men. Tumor size was also larger among men at presentation at a mean of 29.5 mm vs. 15.5 mm, Dr. Kim and her colleagues found.
Current lung cancer screening guidelines vary somewhat, but most recommend annual screening for people aged 55-80 years who have a 30 pack-year or greater smoking history and are current smokers or have quit within the last 15 years.
Prior studies to see whether longer screening intervals were safe have yielded mixed results, possibly because of differences in clinical and radiologic presentation between men and women, Dr. Kim said.
To explore sex differences in lung cancer at the time of diagnosis, she and her colleagues retrospectively reviewed records for 46,766 patients who underwent screening at their center from January 2000 through February 2016, during which time, 282 patients were diagnosed with lung cancer. Of this group, 186 were diagnosed from the initial screening CT scan, and 96 – the cohort included in the study – were diagnosed from subsequent scans.
The authors found that the majority of men (72%) had solid nodules as the primary pathology. In contrast, ground-glass opacities were the most common nodular finding among women, occurring in 45% of the cases. The most common histology among men was adenocarcinoma (42%), followed by squamous-cell carcinoma (35%), small cell lung cancer (18%), and others (5%). All women presented with adenocarcinoma histology.
“Because ground-glass opacity nodule is the most common feature of lung cancer in women, and all cases are adenocarcinoma, the growth rate of cancers might be low,” Dr. Kim said in a statement.
Only 2 of the 11 women in the study were smokers, compared with 74 of the 85 men.
Looking at the operability of lung cancer according to screening intervals, the investigators found that 100% of tumors detected at 1 year in men were operable, compared with 94% of those detected at 2 years, and 55% for those detected at the 3-year interval. In contrast, among women, there were no tumors detected at 1 year, one operable tumor and no inoperable tumors at 2 years, and two operable and no inoperable tumors at 3 years. Beyond 3 years, however, the rate of inoperable tumors at the time of diagnosis was 32% in men and 25% in women.
“We included all patients screened for lung cancer in a 17-year period, but the number of women patients was low and further studies are needed to confirm the sex differences we found,” Dr. Kim acknowledged.
“Only when this is adjusted for – when we compare smokers of the same pack-year history – then we can look at whether women and men do have different rates of appearance of nodules,” he said.
“To me, this is a very interesting suggestion that indeed the biology of the growth of these nodules may be different in men and women, but only if we are sure that the main environmental factor is taken care of.”
The study funding source was not disclosed.
Dr. Kim and Dr. Boffetta reported no relevant disclosures.
GENEVA – A lung-cancer screening CT interval of once-yearly for men and once every 3 years for women appears to be the optimum schedule for detecting most early-stage lung cancers while minimizing radiation exposure, results of a retrospective study suggest.
Among 96 patients (85 men and 11 women) with lung cancers detected on follow-up screening CT, the mean interval time between initial CT and diagnostic CT was significantly longer among women than among men, at 5.6 vs. 3.6 years (P = .02), reported Mi-Young Kim, MD, a radiologist at Asan Medical Center in Seoul, South Korea.
Men tended to have a higher stage at diagnosis, however. Stage I cancers were diagnosed in 82% of women, but only 49% of men. Tumor size was also larger among men at presentation at a mean of 29.5 mm vs. 15.5 mm, Dr. Kim and her colleagues found.
Current lung cancer screening guidelines vary somewhat, but most recommend annual screening for people aged 55-80 years who have a 30 pack-year or greater smoking history and are current smokers or have quit within the last 15 years.
Prior studies to see whether longer screening intervals were safe have yielded mixed results, possibly because of differences in clinical and radiologic presentation between men and women, Dr. Kim said.
To explore sex differences in lung cancer at the time of diagnosis, she and her colleagues retrospectively reviewed records for 46,766 patients who underwent screening at their center from January 2000 through February 2016, during which time, 282 patients were diagnosed with lung cancer. Of this group, 186 were diagnosed from the initial screening CT scan, and 96 – the cohort included in the study – were diagnosed from subsequent scans.
The authors found that the majority of men (72%) had solid nodules as the primary pathology. In contrast, ground-glass opacities were the most common nodular finding among women, occurring in 45% of the cases. The most common histology among men was adenocarcinoma (42%), followed by squamous-cell carcinoma (35%), small cell lung cancer (18%), and others (5%). All women presented with adenocarcinoma histology.
“Because ground-glass opacity nodule is the most common feature of lung cancer in women, and all cases are adenocarcinoma, the growth rate of cancers might be low,” Dr. Kim said in a statement.
Only 2 of the 11 women in the study were smokers, compared with 74 of the 85 men.
Looking at the operability of lung cancer according to screening intervals, the investigators found that 100% of tumors detected at 1 year in men were operable, compared with 94% of those detected at 2 years, and 55% for those detected at the 3-year interval. In contrast, among women, there were no tumors detected at 1 year, one operable tumor and no inoperable tumors at 2 years, and two operable and no inoperable tumors at 3 years. Beyond 3 years, however, the rate of inoperable tumors at the time of diagnosis was 32% in men and 25% in women.
“We included all patients screened for lung cancer in a 17-year period, but the number of women patients was low and further studies are needed to confirm the sex differences we found,” Dr. Kim acknowledged.
“Only when this is adjusted for – when we compare smokers of the same pack-year history – then we can look at whether women and men do have different rates of appearance of nodules,” he said.
“To me, this is a very interesting suggestion that indeed the biology of the growth of these nodules may be different in men and women, but only if we are sure that the main environmental factor is taken care of.”
The study funding source was not disclosed.
Dr. Kim and Dr. Boffetta reported no relevant disclosures.
FROM ELCC
Key clinical point:
Major finding: A repeated CT scan for lung cancer every year in men and every 3 years in women picked up most new, operable lesions.
Data source: Retrospective review of data on 96 patients with lung cancer diagnosed at a second or subsequent CT screening.
Disclosures: The study funding source was not disclosed. Dr. Kim and Dr. Boffetta reported no relevant disclosures.
Low-income uninsured trauma patients at risk for ruinous medical costs
Almost three-quarters of uninsured adults admitted for traumatic injury are at risk of catastrophic health expenditures (CHEs), according to a large retrospective study from a national patient database.
Since enactment of the Affordable Care Act in 2010, the number of uninsured individuals has dropped substantially, but there remains a large population of younger adults, many from low-income areas, who still are not covered. The Centers for Disease Control and Prevention reported in 2015 that 12.8% of individuals aged 18-64 years were uninsured. The financial impact of a traumatic injury is likely to be significant for those paying out of pocket, but the question of who is at risk and to what degree is understudied, according to John W. Scott, MD, of Brigham and Women’s Hospital, Boston, and his colleagues.
“Defining populations at risk of financial catastrophe after medical expense is a necessary step towards elucidating the effect of health care reforms intended to increase access to healthcare through insurance expansion,” they wrote in the Annals of Surgery (2017 Apr 7. doi: 10.1097/SLA.0000000000002254).
Dr. Scott and his colleagues analyzed trauma diagnoses in adults aged 18-64 years from Nationwide Inpatient Sample 2007-2011. They used the U.S. Census data to estimate post-subsistence income (income remaining after paying for food) and hospital charges for trauma diagnoses. The sample of 117,502 patient encounters was weighted to represent 579,683 trauma patients in the national database.
CHEs were defined conservatively as expenses that exceed 40% of a patient’s post-subsistence income; they also applied a lower threshold of CHEs – 10% of a patient’s entire income – without accounting for subsistence needs.
The investigators wanted to look at who was at greatest risk for CHEs and used the Census data to sort trauma patients by residential zip code to identify the distribution of income in the sample.
Costs to trauma patients varied by injury severity score (ISS) and by income quartile. Patients in the 25th income quartile paid less for their treatment, even accounting for ISS, but despite this difference, poorer patients were at a much greater risk for CHEs.
The median charge for all of these uninsured trauma patients was $27,420. Those trauma patients in the 25th percentile of income were charged an average of $15,196, while those in 75th quartile were charged $49,696. The difference in costs also was evident when comparing patients in different ISS categories: for ISS 9-15, median trauma costs for the lower-quartile patients was $31,095, but costs for the upper quartile patients was $52,639.
With cost, income, and injury severity data, the investigators found that overall the proportion of adults aged 18-64 years at risk for CHEs was 70.8% (95% confidence interval, 70.7%-71.1%). Subpopulations (ethnicity/race, age, sex) were within a few percentage point of each other.
Risk of CHEs varied widely by income quartile and ISS. Uninsured trauma patients in the highest income quartile had a 52.9% risk of CHEs, compared with 77.5% of those in the lowest-income quartile. Overall, 81.8% of patients with ISS greater than 24 were at risk for CHEs. In addition, the study found that patients treated at large or urban teaching hospitals – those most likely to handle the most-severely injured patients – were at a heightened risk for CHEs.
When the investigators conducted the same analysis with a lower threshold of CHEs (10% of income, not including subsistence expenses), the overall risk for uninsured trauma patients for catastrophic health expenses was more than 90%.
“Trauma patients are at particularly high risk for CHE because trauma disproportionately affects uninsured patients with little disposable income and because trauma injuries commonly affect multiple organ systems and incur expensive, multispecialty care,” Dr. Scott and his colleagues wrote. “Large unpaid medical debts may have longstanding impacts on patients’ financial well-being, affecting credit ratings and overall financial solvency. These financial stresses may be further compounded by an inability to return to work caused by injury.”
Dr. Scott and his coauthors added that having health insurance does not entirely eliminate the risk for CHEs and that individuals in the lower income brackets covered by employer-based plans or Medicaid had difficulty paying medical bills.
Only hospital costs were examined, which may not reflect forgiven debts, the investigators noted. In addition, the costs may be underreported because they do not include physician charges, postacute care, home health care, or rehabilitation. Incomes were estimated by zip code analysis, which may misclassify some individuals.
“Efforts are needed to ensure that the lifesaving care provided by our highly coordinated trauma systems do not have the unintended consequence of curing patients into destitution,” Dr. Scott and his colleagues wrote
The authors declared no conflicts of interest.
Almost three-quarters of uninsured adults admitted for traumatic injury are at risk of catastrophic health expenditures (CHEs), according to a large retrospective study from a national patient database.
Since enactment of the Affordable Care Act in 2010, the number of uninsured individuals has dropped substantially, but there remains a large population of younger adults, many from low-income areas, who still are not covered. The Centers for Disease Control and Prevention reported in 2015 that 12.8% of individuals aged 18-64 years were uninsured. The financial impact of a traumatic injury is likely to be significant for those paying out of pocket, but the question of who is at risk and to what degree is understudied, according to John W. Scott, MD, of Brigham and Women’s Hospital, Boston, and his colleagues.
“Defining populations at risk of financial catastrophe after medical expense is a necessary step towards elucidating the effect of health care reforms intended to increase access to healthcare through insurance expansion,” they wrote in the Annals of Surgery (2017 Apr 7. doi: 10.1097/SLA.0000000000002254).
Dr. Scott and his colleagues analyzed trauma diagnoses in adults aged 18-64 years from Nationwide Inpatient Sample 2007-2011. They used the U.S. Census data to estimate post-subsistence income (income remaining after paying for food) and hospital charges for trauma diagnoses. The sample of 117,502 patient encounters was weighted to represent 579,683 trauma patients in the national database.
CHEs were defined conservatively as expenses that exceed 40% of a patient’s post-subsistence income; they also applied a lower threshold of CHEs – 10% of a patient’s entire income – without accounting for subsistence needs.
The investigators wanted to look at who was at greatest risk for CHEs and used the Census data to sort trauma patients by residential zip code to identify the distribution of income in the sample.
Costs to trauma patients varied by injury severity score (ISS) and by income quartile. Patients in the 25th income quartile paid less for their treatment, even accounting for ISS, but despite this difference, poorer patients were at a much greater risk for CHEs.
The median charge for all of these uninsured trauma patients was $27,420. Those trauma patients in the 25th percentile of income were charged an average of $15,196, while those in 75th quartile were charged $49,696. The difference in costs also was evident when comparing patients in different ISS categories: for ISS 9-15, median trauma costs for the lower-quartile patients was $31,095, but costs for the upper quartile patients was $52,639.
With cost, income, and injury severity data, the investigators found that overall the proportion of adults aged 18-64 years at risk for CHEs was 70.8% (95% confidence interval, 70.7%-71.1%). Subpopulations (ethnicity/race, age, sex) were within a few percentage point of each other.
Risk of CHEs varied widely by income quartile and ISS. Uninsured trauma patients in the highest income quartile had a 52.9% risk of CHEs, compared with 77.5% of those in the lowest-income quartile. Overall, 81.8% of patients with ISS greater than 24 were at risk for CHEs. In addition, the study found that patients treated at large or urban teaching hospitals – those most likely to handle the most-severely injured patients – were at a heightened risk for CHEs.
When the investigators conducted the same analysis with a lower threshold of CHEs (10% of income, not including subsistence expenses), the overall risk for uninsured trauma patients for catastrophic health expenses was more than 90%.
“Trauma patients are at particularly high risk for CHE because trauma disproportionately affects uninsured patients with little disposable income and because trauma injuries commonly affect multiple organ systems and incur expensive, multispecialty care,” Dr. Scott and his colleagues wrote. “Large unpaid medical debts may have longstanding impacts on patients’ financial well-being, affecting credit ratings and overall financial solvency. These financial stresses may be further compounded by an inability to return to work caused by injury.”
Dr. Scott and his coauthors added that having health insurance does not entirely eliminate the risk for CHEs and that individuals in the lower income brackets covered by employer-based plans or Medicaid had difficulty paying medical bills.
Only hospital costs were examined, which may not reflect forgiven debts, the investigators noted. In addition, the costs may be underreported because they do not include physician charges, postacute care, home health care, or rehabilitation. Incomes were estimated by zip code analysis, which may misclassify some individuals.
“Efforts are needed to ensure that the lifesaving care provided by our highly coordinated trauma systems do not have the unintended consequence of curing patients into destitution,” Dr. Scott and his colleagues wrote
The authors declared no conflicts of interest.
Almost three-quarters of uninsured adults admitted for traumatic injury are at risk of catastrophic health expenditures (CHEs), according to a large retrospective study from a national patient database.
Since enactment of the Affordable Care Act in 2010, the number of uninsured individuals has dropped substantially, but there remains a large population of younger adults, many from low-income areas, who still are not covered. The Centers for Disease Control and Prevention reported in 2015 that 12.8% of individuals aged 18-64 years were uninsured. The financial impact of a traumatic injury is likely to be significant for those paying out of pocket, but the question of who is at risk and to what degree is understudied, according to John W. Scott, MD, of Brigham and Women’s Hospital, Boston, and his colleagues.
“Defining populations at risk of financial catastrophe after medical expense is a necessary step towards elucidating the effect of health care reforms intended to increase access to healthcare through insurance expansion,” they wrote in the Annals of Surgery (2017 Apr 7. doi: 10.1097/SLA.0000000000002254).
Dr. Scott and his colleagues analyzed trauma diagnoses in adults aged 18-64 years from Nationwide Inpatient Sample 2007-2011. They used the U.S. Census data to estimate post-subsistence income (income remaining after paying for food) and hospital charges for trauma diagnoses. The sample of 117,502 patient encounters was weighted to represent 579,683 trauma patients in the national database.
CHEs were defined conservatively as expenses that exceed 40% of a patient’s post-subsistence income; they also applied a lower threshold of CHEs – 10% of a patient’s entire income – without accounting for subsistence needs.
The investigators wanted to look at who was at greatest risk for CHEs and used the Census data to sort trauma patients by residential zip code to identify the distribution of income in the sample.
Costs to trauma patients varied by injury severity score (ISS) and by income quartile. Patients in the 25th income quartile paid less for their treatment, even accounting for ISS, but despite this difference, poorer patients were at a much greater risk for CHEs.
The median charge for all of these uninsured trauma patients was $27,420. Those trauma patients in the 25th percentile of income were charged an average of $15,196, while those in 75th quartile were charged $49,696. The difference in costs also was evident when comparing patients in different ISS categories: for ISS 9-15, median trauma costs for the lower-quartile patients was $31,095, but costs for the upper quartile patients was $52,639.
With cost, income, and injury severity data, the investigators found that overall the proportion of adults aged 18-64 years at risk for CHEs was 70.8% (95% confidence interval, 70.7%-71.1%). Subpopulations (ethnicity/race, age, sex) were within a few percentage point of each other.
Risk of CHEs varied widely by income quartile and ISS. Uninsured trauma patients in the highest income quartile had a 52.9% risk of CHEs, compared with 77.5% of those in the lowest-income quartile. Overall, 81.8% of patients with ISS greater than 24 were at risk for CHEs. In addition, the study found that patients treated at large or urban teaching hospitals – those most likely to handle the most-severely injured patients – were at a heightened risk for CHEs.
When the investigators conducted the same analysis with a lower threshold of CHEs (10% of income, not including subsistence expenses), the overall risk for uninsured trauma patients for catastrophic health expenses was more than 90%.
“Trauma patients are at particularly high risk for CHE because trauma disproportionately affects uninsured patients with little disposable income and because trauma injuries commonly affect multiple organ systems and incur expensive, multispecialty care,” Dr. Scott and his colleagues wrote. “Large unpaid medical debts may have longstanding impacts on patients’ financial well-being, affecting credit ratings and overall financial solvency. These financial stresses may be further compounded by an inability to return to work caused by injury.”
Dr. Scott and his coauthors added that having health insurance does not entirely eliminate the risk for CHEs and that individuals in the lower income brackets covered by employer-based plans or Medicaid had difficulty paying medical bills.
Only hospital costs were examined, which may not reflect forgiven debts, the investigators noted. In addition, the costs may be underreported because they do not include physician charges, postacute care, home health care, or rehabilitation. Incomes were estimated by zip code analysis, which may misclassify some individuals.
“Efforts are needed to ensure that the lifesaving care provided by our highly coordinated trauma systems do not have the unintended consequence of curing patients into destitution,” Dr. Scott and his colleagues wrote
The authors declared no conflicts of interest.
FROM ANNALS OF SURGERY
Postop pain may be a predictor for readmission
PHILADELPHIA – How a patient reacts to postoperative pain and how the pain progresses or regresses can be key predictors for 30-day hospital readmissions and emergency department visits after hospital discharge, according to an analysis of more than 200,000 operations in a national database.
The study sample included 211,213 operations in the Veterans Affairs Surgical Quality Improvement Program during 2008-2014, 45% of which were orthopedic in nature, 37% general, and 18% vascular. The overall 30-day unplanned readmission rate was 10.8% and the 30-day ED utilization rate was 14.2%, Dr. Hawn said.
The study identified six distinct postoperative inpatient pain trajectories based on postop pain scores: persistently low (4.5%); mild to low (9%); persistently mild (15.3%); moderate to low (12.1%); persistently moderate (40.2%); and persistently high (18.9%). One of the study objectives, Dr. Hawn said, “was to see if we could identify patterns of postoperative pain trajectories in a surgical cohort, and to describe these subpopulations by their trajectories, and then to determine whether there was an association with postdischarge health care utilization.” The hypothesis was that inpatient postoperative pain trajectory would be associated with 30-day readmission and ED visits as well as postop complications, Dr. Hawn added.
Patients with high pain trajectories had highest rates of postdischarge readmission and ED visits, 14.4% and 16.3%, respectively, Dr. Hawn said.
“Patients in the low-pain categories were more likely to undergo general and vascular procedures compared to orthopedic procedures in the high-pain categories,” Dr. Hawn said. “In the low-pain categories, they were older and less likely to be female. They were less likely to have independent functional status whereas patients in the high-pain category had a 26% prevalence of preoperative diagnosis of depression.”
Those in the high-pain category had a 1.5 times greater risk of an unplanned readmission and a 4 times greater risk in pain-related readmission, according to an odds ratio analysis of the data.
“As for the prevalence of our outcomes, 10.7% had an unplanned readmission. A total of 1.5% from the overall cohort had a pain-related readmission, 8.6% had an emergency visit within 30 days of discharge that did not result in a readmission, and 4.4% had at least one postdischarge complication,” Dr. Hawn said.
In his discussion, Clifford Y. Ko, MD, FACS, of the University of California, Los Angeles, asked what was the take-home for surgeons managing patients postoperatively in the era of the opioid epidemic. “For these types of patients, we need to get our colleagues, the pain specialists, involved much earlier,” Dr. Hawn said. “We need to rethink that strategy of treating the pain-score number. And I think there’s been so much national attention to this that we will stop focusing on that number as a measure of quality of care and patient satisfaction. Those are some trends we’ll see in the future.”
Neither Dr. Hawn nor Dr. Ko reported any financial disclosures
The complete manuscript of this study and its presentation at the American Surgical Association’s 137th Annual Meeting, April 2017, in Philadelphia, is anticipated to be published in the Annals of Surgery pending editorial review.
PHILADELPHIA – How a patient reacts to postoperative pain and how the pain progresses or regresses can be key predictors for 30-day hospital readmissions and emergency department visits after hospital discharge, according to an analysis of more than 200,000 operations in a national database.
The study sample included 211,213 operations in the Veterans Affairs Surgical Quality Improvement Program during 2008-2014, 45% of which were orthopedic in nature, 37% general, and 18% vascular. The overall 30-day unplanned readmission rate was 10.8% and the 30-day ED utilization rate was 14.2%, Dr. Hawn said.
The study identified six distinct postoperative inpatient pain trajectories based on postop pain scores: persistently low (4.5%); mild to low (9%); persistently mild (15.3%); moderate to low (12.1%); persistently moderate (40.2%); and persistently high (18.9%). One of the study objectives, Dr. Hawn said, “was to see if we could identify patterns of postoperative pain trajectories in a surgical cohort, and to describe these subpopulations by their trajectories, and then to determine whether there was an association with postdischarge health care utilization.” The hypothesis was that inpatient postoperative pain trajectory would be associated with 30-day readmission and ED visits as well as postop complications, Dr. Hawn added.
Patients with high pain trajectories had highest rates of postdischarge readmission and ED visits, 14.4% and 16.3%, respectively, Dr. Hawn said.
“Patients in the low-pain categories were more likely to undergo general and vascular procedures compared to orthopedic procedures in the high-pain categories,” Dr. Hawn said. “In the low-pain categories, they were older and less likely to be female. They were less likely to have independent functional status whereas patients in the high-pain category had a 26% prevalence of preoperative diagnosis of depression.”
Those in the high-pain category had a 1.5 times greater risk of an unplanned readmission and a 4 times greater risk in pain-related readmission, according to an odds ratio analysis of the data.
“As for the prevalence of our outcomes, 10.7% had an unplanned readmission. A total of 1.5% from the overall cohort had a pain-related readmission, 8.6% had an emergency visit within 30 days of discharge that did not result in a readmission, and 4.4% had at least one postdischarge complication,” Dr. Hawn said.
In his discussion, Clifford Y. Ko, MD, FACS, of the University of California, Los Angeles, asked what was the take-home for surgeons managing patients postoperatively in the era of the opioid epidemic. “For these types of patients, we need to get our colleagues, the pain specialists, involved much earlier,” Dr. Hawn said. “We need to rethink that strategy of treating the pain-score number. And I think there’s been so much national attention to this that we will stop focusing on that number as a measure of quality of care and patient satisfaction. Those are some trends we’ll see in the future.”
Neither Dr. Hawn nor Dr. Ko reported any financial disclosures
The complete manuscript of this study and its presentation at the American Surgical Association’s 137th Annual Meeting, April 2017, in Philadelphia, is anticipated to be published in the Annals of Surgery pending editorial review.
PHILADELPHIA – How a patient reacts to postoperative pain and how the pain progresses or regresses can be key predictors for 30-day hospital readmissions and emergency department visits after hospital discharge, according to an analysis of more than 200,000 operations in a national database.
The study sample included 211,213 operations in the Veterans Affairs Surgical Quality Improvement Program during 2008-2014, 45% of which were orthopedic in nature, 37% general, and 18% vascular. The overall 30-day unplanned readmission rate was 10.8% and the 30-day ED utilization rate was 14.2%, Dr. Hawn said.
The study identified six distinct postoperative inpatient pain trajectories based on postop pain scores: persistently low (4.5%); mild to low (9%); persistently mild (15.3%); moderate to low (12.1%); persistently moderate (40.2%); and persistently high (18.9%). One of the study objectives, Dr. Hawn said, “was to see if we could identify patterns of postoperative pain trajectories in a surgical cohort, and to describe these subpopulations by their trajectories, and then to determine whether there was an association with postdischarge health care utilization.” The hypothesis was that inpatient postoperative pain trajectory would be associated with 30-day readmission and ED visits as well as postop complications, Dr. Hawn added.
Patients with high pain trajectories had highest rates of postdischarge readmission and ED visits, 14.4% and 16.3%, respectively, Dr. Hawn said.
“Patients in the low-pain categories were more likely to undergo general and vascular procedures compared to orthopedic procedures in the high-pain categories,” Dr. Hawn said. “In the low-pain categories, they were older and less likely to be female. They were less likely to have independent functional status whereas patients in the high-pain category had a 26% prevalence of preoperative diagnosis of depression.”
Those in the high-pain category had a 1.5 times greater risk of an unplanned readmission and a 4 times greater risk in pain-related readmission, according to an odds ratio analysis of the data.
“As for the prevalence of our outcomes, 10.7% had an unplanned readmission. A total of 1.5% from the overall cohort had a pain-related readmission, 8.6% had an emergency visit within 30 days of discharge that did not result in a readmission, and 4.4% had at least one postdischarge complication,” Dr. Hawn said.
In his discussion, Clifford Y. Ko, MD, FACS, of the University of California, Los Angeles, asked what was the take-home for surgeons managing patients postoperatively in the era of the opioid epidemic. “For these types of patients, we need to get our colleagues, the pain specialists, involved much earlier,” Dr. Hawn said. “We need to rethink that strategy of treating the pain-score number. And I think there’s been so much national attention to this that we will stop focusing on that number as a measure of quality of care and patient satisfaction. Those are some trends we’ll see in the future.”
Neither Dr. Hawn nor Dr. Ko reported any financial disclosures
The complete manuscript of this study and its presentation at the American Surgical Association’s 137th Annual Meeting, April 2017, in Philadelphia, is anticipated to be published in the Annals of Surgery pending editorial review.
AT THE ASA ANNUAL
Key clinical point: A higher trajectory of postoperative pain scores may be a predictor of 30-day readmission and emergency department utilization.
Major finding: Patients with high pain trajectories had the highest rates of post-discharge readmission and emergency department visits, 14.4% and 16.3%, respectively.
Data source: Retrospective cohort study of Veterans Affairs’ data on operations on 211,213 operations performed during 2008-2014.
Disclosures: Dr. Hawn and her coauthors reported having no financial disclosures.
Lower limb compression halved epidural-associated hypotension
SAN DIEGO – Use of sequential compression devices reduced by half cases of epidural-associated hypotension in laboring women in a small real-world, randomized controlled trial.
The results showed that patients who received sequential compression devices (SCD) and kept them on for at least an hour after epidural analgesia placement had half the hypotension of patients who had no lower limb compression (33.3% vs. 66.7%; P .022).
“Lower limb compression using SCDs significantly decreased the incidence of maternal hypotension in laboring patients receiving epidural anesthesia,” said Margaret Steinmetz, MD, a third-year resident at the State University of New York at Buffalo.
The study, which was presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists, was a multisite, randomized controlled trial that used a randomized block design to assign women to three groups. The control group received no intervention; the remainder of patients received either thromboembolic deterrent (TED) stockings or sequential compression devices (SCDs) set to intermittent compression and applied before receiving epidural anesthesia.
The facilities’ usual protocols were followed both for epidural placement and for patient management, except for the lower limb compression and the study’s timed blood pressure checks.
Pregnant women who were at term and had requested epidural anesthesia were included if they had a singleton pregnancy; no history of hypertension, cardiovascular disease; and no contraindication to lower limb compression.
Hypotension – defined as at least one decrease in either systolic or diastolic blood pressure of more than 20% from baseline – was tracked by obtaining sequential blood pressure readings. A baseline was established with an average of three readings obtained before epidural placement. Following the epidural bolus, blood pressures were measured at minutes 1, 5, 15, 30, 45, and 60.
The investigators used an intention-to-treat analysis, meaning that they included patients allocated to each group whether or not they actually received lower limb compression. Patients with missing data were excluded.
A total of 82 patients were randomized:
- 28 to the control arm (no lower limb compression); 1 had missing data.
- 26 to receive TEDs (6 of whom did not don the stockings); 5 were excluded from analysis because of missing data or no epidural placement.
- 28 patients to receive SCDs (8 of whom did not have SCDs applied); 5 were excluded from analysis because of missing data or no epidural placement.
While the SCDs cut the incidence of hypotension in half, compared with no compression, women in the TEDs group saw an intermediate result, with a 52.4% incidence of hypotension.
Dr. Steinmetz noted that knee-high TEDs were used. The choice was made in part because the labor and delivery nursing staff were not enthusiastic about the prospect of placing thigh-high TEDs on a woman in labor, she added.
Patient age, mean body mass index, and gestational age did not differ significantly between the study arms. Logistic regression analysis performed to control for clinical site, method of delivery, gestational age, and maternal age and body mass index did not affect the analysis, Dr. Steinmetz added.
Older data showed that about 30% of women getting epidurals in labor experience hypotension, though Dr. Steinmetz said that she believes that the 66.7% seen in this study is probably closer to an accurate estimate.
SUNY Buffalo is looking at changing the labor and delivery protocol to include lower limb compression with epidurals, Dr. Steinmetz said, adding “When I’m on labor and delivery, I definitely encourage the placement of SCDs.”
Some facilities also use lower limb compression to reduce hypotension when patients receive regional anesthesia for cesarean deliveries. Dr. Steinmetz said that there are studies that support that practice, but the literature is not conclusive. Still, it makes sense in this setting too, she said. “C-section patients sit up, they get their spinal, then we lay them down and put in a Foley, and they’re vomiting as we put in the Foley because they’re hypotensive from that spinal. ... For me, myself, when I go into practice in 2 months, yes; I will be wanting to do this.”
Dr. Steinmetz reported no relevant disclosures.
[email protected]
On Twitter @karioakes
SAN DIEGO – Use of sequential compression devices reduced by half cases of epidural-associated hypotension in laboring women in a small real-world, randomized controlled trial.
The results showed that patients who received sequential compression devices (SCD) and kept them on for at least an hour after epidural analgesia placement had half the hypotension of patients who had no lower limb compression (33.3% vs. 66.7%; P .022).
“Lower limb compression using SCDs significantly decreased the incidence of maternal hypotension in laboring patients receiving epidural anesthesia,” said Margaret Steinmetz, MD, a third-year resident at the State University of New York at Buffalo.
The study, which was presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists, was a multisite, randomized controlled trial that used a randomized block design to assign women to three groups. The control group received no intervention; the remainder of patients received either thromboembolic deterrent (TED) stockings or sequential compression devices (SCDs) set to intermittent compression and applied before receiving epidural anesthesia.
The facilities’ usual protocols were followed both for epidural placement and for patient management, except for the lower limb compression and the study’s timed blood pressure checks.
Pregnant women who were at term and had requested epidural anesthesia were included if they had a singleton pregnancy; no history of hypertension, cardiovascular disease; and no contraindication to lower limb compression.
Hypotension – defined as at least one decrease in either systolic or diastolic blood pressure of more than 20% from baseline – was tracked by obtaining sequential blood pressure readings. A baseline was established with an average of three readings obtained before epidural placement. Following the epidural bolus, blood pressures were measured at minutes 1, 5, 15, 30, 45, and 60.
The investigators used an intention-to-treat analysis, meaning that they included patients allocated to each group whether or not they actually received lower limb compression. Patients with missing data were excluded.
A total of 82 patients were randomized:
- 28 to the control arm (no lower limb compression); 1 had missing data.
- 26 to receive TEDs (6 of whom did not don the stockings); 5 were excluded from analysis because of missing data or no epidural placement.
- 28 patients to receive SCDs (8 of whom did not have SCDs applied); 5 were excluded from analysis because of missing data or no epidural placement.
While the SCDs cut the incidence of hypotension in half, compared with no compression, women in the TEDs group saw an intermediate result, with a 52.4% incidence of hypotension.
Dr. Steinmetz noted that knee-high TEDs were used. The choice was made in part because the labor and delivery nursing staff were not enthusiastic about the prospect of placing thigh-high TEDs on a woman in labor, she added.
Patient age, mean body mass index, and gestational age did not differ significantly between the study arms. Logistic regression analysis performed to control for clinical site, method of delivery, gestational age, and maternal age and body mass index did not affect the analysis, Dr. Steinmetz added.
Older data showed that about 30% of women getting epidurals in labor experience hypotension, though Dr. Steinmetz said that she believes that the 66.7% seen in this study is probably closer to an accurate estimate.
SUNY Buffalo is looking at changing the labor and delivery protocol to include lower limb compression with epidurals, Dr. Steinmetz said, adding “When I’m on labor and delivery, I definitely encourage the placement of SCDs.”
Some facilities also use lower limb compression to reduce hypotension when patients receive regional anesthesia for cesarean deliveries. Dr. Steinmetz said that there are studies that support that practice, but the literature is not conclusive. Still, it makes sense in this setting too, she said. “C-section patients sit up, they get their spinal, then we lay them down and put in a Foley, and they’re vomiting as we put in the Foley because they’re hypotensive from that spinal. ... For me, myself, when I go into practice in 2 months, yes; I will be wanting to do this.”
Dr. Steinmetz reported no relevant disclosures.
[email protected]
On Twitter @karioakes
SAN DIEGO – Use of sequential compression devices reduced by half cases of epidural-associated hypotension in laboring women in a small real-world, randomized controlled trial.
The results showed that patients who received sequential compression devices (SCD) and kept them on for at least an hour after epidural analgesia placement had half the hypotension of patients who had no lower limb compression (33.3% vs. 66.7%; P .022).
“Lower limb compression using SCDs significantly decreased the incidence of maternal hypotension in laboring patients receiving epidural anesthesia,” said Margaret Steinmetz, MD, a third-year resident at the State University of New York at Buffalo.
The study, which was presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists, was a multisite, randomized controlled trial that used a randomized block design to assign women to three groups. The control group received no intervention; the remainder of patients received either thromboembolic deterrent (TED) stockings or sequential compression devices (SCDs) set to intermittent compression and applied before receiving epidural anesthesia.
The facilities’ usual protocols were followed both for epidural placement and for patient management, except for the lower limb compression and the study’s timed blood pressure checks.
Pregnant women who were at term and had requested epidural anesthesia were included if they had a singleton pregnancy; no history of hypertension, cardiovascular disease; and no contraindication to lower limb compression.
Hypotension – defined as at least one decrease in either systolic or diastolic blood pressure of more than 20% from baseline – was tracked by obtaining sequential blood pressure readings. A baseline was established with an average of three readings obtained before epidural placement. Following the epidural bolus, blood pressures were measured at minutes 1, 5, 15, 30, 45, and 60.
The investigators used an intention-to-treat analysis, meaning that they included patients allocated to each group whether or not they actually received lower limb compression. Patients with missing data were excluded.
A total of 82 patients were randomized:
- 28 to the control arm (no lower limb compression); 1 had missing data.
- 26 to receive TEDs (6 of whom did not don the stockings); 5 were excluded from analysis because of missing data or no epidural placement.
- 28 patients to receive SCDs (8 of whom did not have SCDs applied); 5 were excluded from analysis because of missing data or no epidural placement.
While the SCDs cut the incidence of hypotension in half, compared with no compression, women in the TEDs group saw an intermediate result, with a 52.4% incidence of hypotension.
Dr. Steinmetz noted that knee-high TEDs were used. The choice was made in part because the labor and delivery nursing staff were not enthusiastic about the prospect of placing thigh-high TEDs on a woman in labor, she added.
Patient age, mean body mass index, and gestational age did not differ significantly between the study arms. Logistic regression analysis performed to control for clinical site, method of delivery, gestational age, and maternal age and body mass index did not affect the analysis, Dr. Steinmetz added.
Older data showed that about 30% of women getting epidurals in labor experience hypotension, though Dr. Steinmetz said that she believes that the 66.7% seen in this study is probably closer to an accurate estimate.
SUNY Buffalo is looking at changing the labor and delivery protocol to include lower limb compression with epidurals, Dr. Steinmetz said, adding “When I’m on labor and delivery, I definitely encourage the placement of SCDs.”
Some facilities also use lower limb compression to reduce hypotension when patients receive regional anesthesia for cesarean deliveries. Dr. Steinmetz said that there are studies that support that practice, but the literature is not conclusive. Still, it makes sense in this setting too, she said. “C-section patients sit up, they get their spinal, then we lay them down and put in a Foley, and they’re vomiting as we put in the Foley because they’re hypotensive from that spinal. ... For me, myself, when I go into practice in 2 months, yes; I will be wanting to do this.”
Dr. Steinmetz reported no relevant disclosures.
[email protected]
On Twitter @karioakes
AT ACOG 2017
Key clinical point:
Major finding: The rate of hypotension for women in labor who received epidurals was 66.7% with no lower limb compression, compared with 33.3% when sequential compression devices were used (P –.02).
Data source: Multisite randomized controlled trial of 82 patients who received epidurals while in labor.
Disclosures: The study authors reported no outside sources of funding, and reported no conflicts of interest.
Enzyme tablet eases pain of gluten consumption
CHICAGO – Gluten-sensitive patients were able to tolerate small amounts of gluten after consuming an enzyme supplement derived from Aspergillus niger as part of a meal in a randomized, placebo-controlled trial of 18 adults. The data were presented at the annual Digestive Disease Week.
The enzyme, A. niger-derived prolyl endoprotease (AN-PEP), has demonstrated the ability to degrade gluten into nonimmunogenic compounds in vivo in healthy subjects, according to Julia König, PhD, of the School of Medical Sciences, Örebro (Sweden) University and her colleagues. The researchers tested the enzyme at two separate doses in 18 adults with self-reported gluten sensitivity.
The participants’ gastric and duodenal content was sampled several times over 180 minutes and analyzed for gluten epitopes using an enzyme-linked immunosorbent assay test. Participants also completed questionnaires after each day of testing.
After taking the enzyme in conjunction with the gluten, stomach gluten content averaged 31 microg x min/mL in the high-dose and low-dose enzyme patients (P = 0.001 for both doses), compared with 281 microg x min/mL in the placebo patients.
By the time the gluten reached the duodenum, the average levels had dropped to 12 microg x min/mL in the high-dose patients (P = 0.019) and 8 microg x min/mL in the low-dose patients (P = 0.015), compared with an average of 65 microg x min/mL in the placebo patients.
Overall, the enzyme was well tolerated by the patients, the researchers said. However, Dr. König emphasized that the enzyme tablet is meant to help avoid symptoms when gluten-sensitive patients encounter small amounts of gluten, and these patients should still follow a gluten-free diet.
AN-PEP is available in the United States in supplement form under several names and is manufactured by the Dutch company DSM. The AN-PEP enzyme used in the study was provided by DSM, but the company provided no other support. Dr. König had no relevant financial conflicts to disclose.
Digestive Disease Week® is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).
CHICAGO – Gluten-sensitive patients were able to tolerate small amounts of gluten after consuming an enzyme supplement derived from Aspergillus niger as part of a meal in a randomized, placebo-controlled trial of 18 adults. The data were presented at the annual Digestive Disease Week.
The enzyme, A. niger-derived prolyl endoprotease (AN-PEP), has demonstrated the ability to degrade gluten into nonimmunogenic compounds in vivo in healthy subjects, according to Julia König, PhD, of the School of Medical Sciences, Örebro (Sweden) University and her colleagues. The researchers tested the enzyme at two separate doses in 18 adults with self-reported gluten sensitivity.
The participants’ gastric and duodenal content was sampled several times over 180 minutes and analyzed for gluten epitopes using an enzyme-linked immunosorbent assay test. Participants also completed questionnaires after each day of testing.
After taking the enzyme in conjunction with the gluten, stomach gluten content averaged 31 microg x min/mL in the high-dose and low-dose enzyme patients (P = 0.001 for both doses), compared with 281 microg x min/mL in the placebo patients.
By the time the gluten reached the duodenum, the average levels had dropped to 12 microg x min/mL in the high-dose patients (P = 0.019) and 8 microg x min/mL in the low-dose patients (P = 0.015), compared with an average of 65 microg x min/mL in the placebo patients.
Overall, the enzyme was well tolerated by the patients, the researchers said. However, Dr. König emphasized that the enzyme tablet is meant to help avoid symptoms when gluten-sensitive patients encounter small amounts of gluten, and these patients should still follow a gluten-free diet.
AN-PEP is available in the United States in supplement form under several names and is manufactured by the Dutch company DSM. The AN-PEP enzyme used in the study was provided by DSM, but the company provided no other support. Dr. König had no relevant financial conflicts to disclose.
Digestive Disease Week® is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).
CHICAGO – Gluten-sensitive patients were able to tolerate small amounts of gluten after consuming an enzyme supplement derived from Aspergillus niger as part of a meal in a randomized, placebo-controlled trial of 18 adults. The data were presented at the annual Digestive Disease Week.
The enzyme, A. niger-derived prolyl endoprotease (AN-PEP), has demonstrated the ability to degrade gluten into nonimmunogenic compounds in vivo in healthy subjects, according to Julia König, PhD, of the School of Medical Sciences, Örebro (Sweden) University and her colleagues. The researchers tested the enzyme at two separate doses in 18 adults with self-reported gluten sensitivity.
The participants’ gastric and duodenal content was sampled several times over 180 minutes and analyzed for gluten epitopes using an enzyme-linked immunosorbent assay test. Participants also completed questionnaires after each day of testing.
After taking the enzyme in conjunction with the gluten, stomach gluten content averaged 31 microg x min/mL in the high-dose and low-dose enzyme patients (P = 0.001 for both doses), compared with 281 microg x min/mL in the placebo patients.
By the time the gluten reached the duodenum, the average levels had dropped to 12 microg x min/mL in the high-dose patients (P = 0.019) and 8 microg x min/mL in the low-dose patients (P = 0.015), compared with an average of 65 microg x min/mL in the placebo patients.
Overall, the enzyme was well tolerated by the patients, the researchers said. However, Dr. König emphasized that the enzyme tablet is meant to help avoid symptoms when gluten-sensitive patients encounter small amounts of gluten, and these patients should still follow a gluten-free diet.
AN-PEP is available in the United States in supplement form under several names and is manufactured by the Dutch company DSM. The AN-PEP enzyme used in the study was provided by DSM, but the company provided no other support. Dr. König had no relevant financial conflicts to disclose.
Digestive Disease Week® is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).
FROM DDW
Key clinical point: Consuming an enzyme tablet simultaneously with small amounts of gluten may reduce discomfort in gluten-sensitive individuals.
Major finding: On average, gluten levels in the stomach after enzyme consumption were 31 microg x min/mL in both high- and low-dose groups, vs. 281 microg x min/mL in a placebo group.
Data source: A randomized, placebo-controlled trial of 18 gluten-sensitive adults.
Disclosures: The enzyme used in the study, AN-PEP, was provided by the Dutch company DSM, but the company provided no other support. Dr. König had no relevant financial conflicts to disclose.