983280 Nebraska Medical Ctr
Omaha NE 68198
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Can surgical performance benchmarking be generalized across multiple outcomes databases: a comparison of University HealthSystem Consortium and National Surgical Quality Improvement Program. - American journal of surgery
Surgeon's performance is tracked using patient outcomes databases. We compared data on patients undergoing laparoscopic cholecystectomy from 2 large databases with significant institutional overlap to see if either patient characteristics or outcomes were similar enough to accurately compare performance.Data from 2009 to 2011 were collected from University HealthSystem Consortium (UHC) and National Surgical Quality Improvement Program (NSQIP). UHC and NSQIP collect data from over 200 and 400 medical centers, respectively, with an overlap of 70. Patient demographics, pre-existing medical conditions, operative details, and outcomes were compared.Fifty-six thousand one hundred ninety-seven UHC patients and 56,197 NSQIP patients met criteria. Groups were matched by age, sex, and pre-existing comorbidities. Outcomes for NSQIP and UHC differed, including mortality (.20% NSQIP vs .12% UHC; P < .0001), morbidity (2.0% vs 1.5%; P < .0001), wound infection (.07% vs .33%; P < .0001), pneumonia (.38% vs .75%; P < .0001), urinary tract infections (.62% vs .01%; P < .0001), and length of hospital stay (1.8 Â± 7.5 vs 3.8 Â± 3.7Â days; P = .0004), respectively.Surgical outcomes are significantly different between databases and resulting performance data may be significantly biased. A single unified national database may be required to correct this problem.Copyright Â© 2014 Elsevier Inc. All rights reserved.
Alvimopan reduces length of stay and costs in patients undergoing segmental colonic resections: results from multicenter national administrative database. - American journal of surgery
Alvimopan (Entereg), a peripherally acting mu-opioid receptor antagonist, has been shown to expedite recovery of bowel function after colon resection surgery. Most data are available from industry-sponsored trials. This study aims to evaluate the clinical impact of this drug on perioperative outcomes and costs in patients undergoing segmental colonic resection for diverticular disease.A large administrative database maintained by the University Health System Consortium, an alliance of over 200 academic and affiliate hospitals, was queried from 2008 to 2011. International Classification of Diseases, 9th Revision, Clinical Modification codes for segmental colon resection because of diverticular disease were used to identify 2 matched cohorts of adult patients. University Health System Consortium's clinical resource manager was used to access pharmacy data and compare it with patient outcomes.Five thousand two hundred ninety-nine patients met the above criteria. Four hundred thirty-eight patients received alvimopan and 4,861 did not. Regardless of laparoscopic or open approach, alvimopan significantly improved the postoperative length of stay (4.43 Â± 2.02 vs 5.92 Â± 3.79, P < .0001), cost (9,974 Â± 4,077 vs 11,303 Â± 6,968, P < .0001), and intensive care unit admission rate (1.83% vs 7.20%, P < .05), with no significant difference in mortality (.0% vs .19%, P = 1.000), morbidity (5.93% vs 8.39%, P = .08), or 30-day readmission rate (4.40% vs 4.63%, P = .90).Alvimopan significantly reduced length of stay, days in the intensive care unit, and hospital cost for patients undergoing colonic segmental resections. Unlike some previously reported studies, we also observed a significant reduction in the length of stay in patients undergoing laparoscopic colectomies who received the drug. Alvimopan may reduce total healthcare costs if used as part of a best care practice model for colon resections.Copyright Â© 2014 Elsevier Inc. All rights reserved.
Long-term outcomes of radiologic recurrence after paraesophageal hernia repair with mesh. - Surgical endoscopy
Paraesophageal hernia (PEH) repair has a high radiologic recurrence rate, even with the use of biologic mesh as a prosthetic buttress to reinforce the primary crural repair. This review was done to evaluate outcomes after PEH repair with mesh.A retrospective analysis was done of all patients who underwent PEH repair with mesh at our institution between December 2004 and March 2013. Patients were reviewed for evidence of recurrence on upper gastrointestinal studies (UGI). Time-specific, mesh-specific, and size-specific recurrence was analyzed as well as pre- and postoperative symptom scores.A total of 209 patients underwent PEH repair with mesh. Mean follow-up was 25 months (range 0-101). In all cases, an absorbable mesh was used (159 Alloderm, 35 BioA, 15 Strattice). One hundred and fifty-six (75 %) were 5 cm or larger. Of the patients, 166 (79 %) had UGIs available to review for radiologic recurrence. Total recurrence was 21 % (n = 35). No mesh erosions were seen. Recurrence rates increased over time from 16 % (n = 23) at 1 year up to 39 % after 5-year follow-up (n = 11). Recurrence rates were higher for large hernias (23 vs. 16 %). The median size of the recurrence was 4 cm (range 2-7 cm). Overall, patients showed significant improvement in their symptom scores. At long-term follow-up, heartburn had 70.6 % reduction (p < 0.05) and regurgitation had 76.5 % reduction (p < 0.05). There was no significant difference in postoperative symptom scores between patients with or without radiologic recurrence.In this study, PEH repair with mesh was safe and effective at controlling symptoms over the long term. Radiologic recurrence rate increased over time and was highest in patients with hernias >5 cm. Therefore, in our experience, PEH repair with mesh is a safe therapy and though radiologic recurrence does increase with time, symptom resolution is maintained.
How does robotic anti-reflux surgery compare with traditional open and laparoscopic techniques: a cost and outcomes analysis. - Surgical endoscopy
Conventional laparoscopic fundoplications (CLF) have been the gold standard for Nissen fundoplications (NFs) for two decades. The advent of a robotic approach for fundoplication procedures creates a potential alternative. Thus, we used a national database to examine perioperative outcomes with respect to open, laparoscopic, and robotic approaches.The University Health System Consortium is an alliance of medical centers, numbering over 115 academic institutions and their 271 affiliated hospitals. We used International Classification of Diseases codes to elicit patients over the age of 18 years who received NF procedures.A total of 12,079 patients of similar demographic background received fundoplication procedures from October 2008 to June 2012. Of those, 2,168 were open fundoplications (OF), 9,572 were CLF, and 339 were robot-assisted laparoscopic fundoplications (RLF). CLF and RLF displayed no significance in mortality (0.1 vs. 0 %; p = 0.5489), morbidity (4.0 vs. 5.6 %; p = 0.1744), length of stay (2.8 Â± 3.6 vs. 3.0 Â± 3.5; p = 0.3242), and intensive care unit (ICU) cases (8.4 vs. 11.5 %; p = 0.051). However, CLF remained superior, with a lower 30-day re-admission rate (1.8 vs. 3.6 %; p < 0.05) and cost (US$7,968 Â± 6,969 vs. US$10,644 Â± 6,041; p < 0.05). When RLF was compared with OF, RLF had significantly improved morbidity (5.6 vs. 11 %; p < 0.05), length of stay (6.1 Â± 7.2 vs. 3.0 Â± 3.5 days; p < 0.05), less ICU admission (11.5 vs. 23.1 %; p <0.05) and less cost (US$10,644 Â± 6,041 vs. US$12,766 Â± 13,982; p < 0.05).Current data suggests that robot-assisted NF procedures have similar patient outcomes to conventional laparoscopic NF, with the exception of added cost and higher re-admission rate. While the higher costs are expected given the new technology, increasing re-admission rates are concerning and may represent the level of experience of the surgeon as well as the robotic learning curve.
Long-term patient outcomes after laparoscopic anti-reflux procedures. - Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract
Laparoscopic anti-reflux surgery with or without large hiatal hernia has been shown to have good short-term outcomes. However, limited data are available on long-term outcomes of greater than 5 years. The aim of this study is to review functional and symptomatic outcomes of anit-reflux surgery in a large tertiary referral medical center.Two hundred ninety-seven patients who underwent anti-reflux surgery at the University of Nebraska Medical Center between 2002 and 2013 were included in this study. Patient data including pre- and post-operative studies and symptom questionnaires were prospectively collected and the database was used to analyze postoperative outcomes.A total of 297 Nissen fundoplications, 35 redo fundoplications and 22 Toupet procedures were performed. Mean BMI was 30.0â€‰Â±â€‰6.2. The median follow-up was 70 (6-135)â€‰months. There were three reoperations (0.9 %) for recurrent symptoms. Mesh was used in 210 cases where hiatal hernia was larger than 2 cm. Median preoperative DeMeester score was 50.8â€‰Â±â€‰46. There was a statistically significant improvement in composite heartburn score (83 % (CI 78.2, 87.7); pâ€‰<â€‰0.05), regurgitation (81.1 % (CI 76.1, 86.1); pâ€‰<â€‰0.05), and belching (63 % (CI 56.7, 69.3); pâ€‰<â€‰0.05). Atypical presentation such as pulmonary (e.g., aspiration (25.8 % (CI 20, 31.6), wheezing (20.3 % (CI 15, 25.6); pâ€‰<â€‰0.05), and throat symptoms (e.g., laryngitis 28 % (CI 22.1, 33.9); pâ€‰<â€‰0.05) also improved. Available radiographic studies for patients more than 3 years follow-up show an overall recurrence of 33.9 % (47.8 % in hiatal herniaâ€‰>â€‰5 cm repaired with mesh). Of those with recurrence, over 84 % were asymptomatic at follow-up.This study shows that patients had excellent symptom control and low rates of complications and reoperations in long-term follow-up. We found that typical gastro intestinal symptoms responded better compared with atypical symptoms in spite of clear evidence of reflux on preoperative studies. Hiatal hernia was very commonly seen in our patient population and long-term radiographic follow-up suggest that asymptomatic recurrence may be high but rarely requires any surgical intervention. Anti-reflux surgery with correction of hiatal hernia if present is safe and effective in long-term follow-up.
Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study. - American journal of surgery
Morbidity and mortality are very high for critically ill patients who develop acute acalculous cholecystitis (AAC). The aim of this study was to compare outcomes in extremely ill patients with AAC treated with percutaneous cholecystostomy (PC), laparoscopic cholecystectomy (LC), or open cholecystectomy (OC), which were also analyzed together in the LC-plus-OC (LO) group.Discharge data from the University HealthSystem Consortium database were accessed using International Classification of Diseases codes. The University HealthSystem Consortium's Clinical Data Base/Resource Manager allows member hospitals to compare patient-level, risk-adjusted outcomes. Multivariate regression models for extremely ill patients undergoing PC or LO for the diagnosis of AAC were created and analyzed.A total of 1,725 extremely ill patients were diagnosed with AAC between October 2007 and June 2011. Patients undergoing PC (n = 704) compared with the LO group (n = 1,021) showed decreased morbidity (5.0% with PC vs 8.0% with LO, P < .05), fewer intensive care unit admissions (28.1% with PC vs 34.6% with LO, P < .05), decreased length of stay (7 days with PC vs 8 days with LO, P < .05), and lower costs ($40,516 with PC vs $53,011 with LO, P < .05). Although perioperative outcomes of PC compared with LC were statistically similar, PC had lower costs compared with LC ($40,516 vs 51,596, P < .005). Multivariate regression analysis showed that LC (n = 822), compared with OC (n = 199), had lower mortality (odds ratio [OR], .3; 95% confidence interval [CI], .1 to .6), lower morbidity (OR, .4; 95% CI, .2 to .7), reduced intensive care unit admission (OR, .3; 95% CI, .2 to .5), and similar 30-day readmission rates (OR, 1.0; 95% CI, .6 to 1.5). Also, decreased length of stay (7 days with LC vs 8 days with OC) and costs ($51,596 with LC vs $61,407 with OC) were observed, with a 26% conversion rate to an open procedure.On the basis of this experience, extremely ill patients with AAC have superior outcomes with PC. LC should be performed in patients in whom the risk for conversion is low and in whom medical conditions allow. These results show PC to be a safe and cost-effective bridge treatment strategy with perioperative outcomes superior to those of OC.Copyright Â© 2013 Elsevier Inc. All rights reserved.
Can laparoscopy for colon resection reduce the need for discharge to skilled care facility? - Surgical endoscopy
A significant proportion of patients, especially the elderly undergoing colon resections, are likely to be discharged to a skilled care facility. This study aims to examine whether the technique of colectomy, open versus laparoscopic, contributed to their discharge to a skilled care facility.This was a retrospective analysis using discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Adult patients who underwent colectomy in 2009 were evaluated. SAS and SUDAAN software were used to provide weighted estimates and to account for the complex sampling design of the NIS. We compared routine discharge to nonroutine discharge, defined as transfer to short-term hospital, skilled nursing facility, intermediate care, home health, or another type of facility.A weighted total of 221,294 adult patients underwent colectomy in 2009 and had the primary outcome of discharge available. Of these colon resections, 70,361 (32 %) were performed laparoscopically and 150,933 (68 %) by open technique. A total of 139,047 (62.8 %) patients had routine discharge and 73,572 (33.3 %) nonroutine. A total of 8,445 (3.8 %) patients died while in the hospital, and 229 (0.1 %) left against medical advice and were excluded from further analysis. On univariate analysis, age â‰¥ 65 years, female gender, Black/Hispanic race, open technique (compared to laparoscopic), Medicare/Medicaid insurance status, comorbidity index of â‰¥ 1, and malignant primary diagnosis predicted nonroutine discharge. A multivariate logistic model was then used to predict nonroutine discharge in these patients using variables significant in the univariate analysis at the Î± = 0.05 significance level. In the multivariate analysis, open compared to laparoscopic technique was independently associated with increased likelihood of discharge to skilled care facilities (odds ratio 2.85, 95 % confidence interval 2.59-3.14).In addition to the expected factors like advancing age, female gender, and increasing comorbidity index, open compared to laparoscopic technique for colectomy is associated with an increased likelihood of discharge to skilled care facilities. When feasible, the laparoscopic technique should be considered as an option, especially in the elderly patients who require colon resection, because it may reduce their likelihood of discharge to a skilled care facility.
Do you need a computed tomographic scan to evaluate suspected appendicitis in young men: an administrative database review. - American journal of surgery
The purpose of this study was to evaluate the impact of computed tomographic (CT) scans of the abdomen on clinical outcomes and costs in young male patients presenting with suspected appendicitis.Discharge data from the University HealthSystem Consortium was accessed for all male patients between 18 and 55 years of age from October 2007 to June 2011.Of a total of 13,228 patients who met the inclusion criteria, 11,340 (85%) were assessed using a CT scan of the abdomen, whereas 1,888 (15%) did not undergo CT evaluation. Patients undergoing CT imaging compared with those without a CT scan had less morbidity (.86% vs 2.2%, P < .0001) and fewer 30-day readmissions (1.8% vs 5.13%, P < .0001). However, CT imaging resulted in a higher overall length of hospital stay and a higher total cost.This study suggests that in young men with suspected appendicitis, the use of an abdominal CT scan is associated with improved immediate postoperative complications, lower readmission rates with observed higher length of stay, and increased cost of care.Copyright Â© 2012 Elsevier Inc. All rights reserved.
Laparoscopic colon resection trends in utilization and rate of conversion to open procedure: a national database review of academic medical centers. - Annals of surgery
This study aims to examine trends of utilization and rates of conversion to open procedure for patients undergoing laparoscopic colon resections (LCR).This study is a national database review of academic medical centers and a retrospective analysis utilizing the University HealthSystem Consortium administrative database-an alliance of more than 300 academic and affiliate hospitals.A total of 85,712 patients underwent colon resections between October 2008 and December 2011. LCR was attempted in 36,228 patients (42.2%), with 5751 patients (15.8%) requiring conversion to an open procedure. There was a trend toward increasing utilization of LCR from 37.5% in 2008 to 44.1% in 2011. Attempted laparoscopic transverse colectomy had the highest rate of conversion (20.8%), followed by left (20.7%), right (15.6%), and sigmoid (14.3%) colon resections. The rate of utilization was highest in the Mid-Atlantic region (50.5%) and in medium- to large-sized hospitals (47.0%-49.0%).Multivariate logistic regression has shown that increasing age [odds ratio (OR) = 4.8, 95% confidence interval (CI) = 3.6-6.4], male sex (OR = 1.2, 95% CI = 1.1-1.3), open as compared with laparoscopic approach (OR = 2.6, 95%, CI = 2.3-3.1), and greater severity of illness category (OR = 27.1, 95% CI = 23.0-31.9) were all associated with increased mortality and morbidity and prolonged length of hospital stay.There is a trend of increasing utilization of LCR, with acceptable conversion rates, across hospitals in the United States over the recent years. When feasible, attempted LCR had better outcomes than open colectomy in the immediate perioperative period.
Trends in adolescent bariatric surgery evaluated by UHC database collection. - Surgical endoscopy
With increasing childhood obesity, adolescent bariatric surgery has been increasingly performed. We used a national database to analyze current trends in laparoscopic bariatric surgery in the adolescent population and related short-term outcomes.Discharge data from the University Health System Consortium (UHC) database was accessed using International Classification of Disease codes during a 36 month period. UHC is an alliance of more than 110 academic medical centers and nearly 250 affiliate hospitals. All adolescent patients between 13 and 18 years of age, with the assorted diagnoses of obesity, who underwent laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (SG), and laparoscopic Roux-en-Y gastric bypass (LRYGB) were evaluated. The main outcome measures analyzed were morbidity, mortality, length of hospital stay (LOS), overall cost, intensive care unit (ICU) admission rate, and readmission rate. These outcomes were compared to those of adult bariatric surgery.Adolescent laparoscopic bariatric surgery was performed on 329 patients. At the same time, 49,519 adult bariatric surgeries were performed. One hundred thirty-six adolescent patients underwent LAGB, 47 had SG, and 146 patients underwent LRYGB. LAGB has shown a decreasing trend (n = 68, 34, and 34), while SG has shown an increasing trend (n = 8, 15, and 24) over the study years. LRYGB remained stable (n = 44, 60, and 42) throughout the study period. The individual and summative morbidity and mortality rates for these procedures were zero. Compared to adult bariatric surgery, 30 day in-hospital morbidity (0 vs. 2.2 %, p < 0.02), the LOS (1.99 Â± 1.37 vs. 2.38 Â± 3.19, p < 0.03), and 30 day readmission rate (0.30 vs. 2.02 %, p < 0.05) are significantly better for adolescent bariatric surgery, while the ICU admission rate (9.78 vs. 6.30 %, p < 0.02) is higher and overall cost ($9,375 Â± 6,452 vs. $9,600 Â± 8,016, p = 0.61) is comparable.Trends in adolescent laparoscopic bariatric surgery reveal the increased use of sleeve gastrectomy and adjustable gastric banding falling out of favor.
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