Introduction The optimal methodology for assessing comorbidity to predict various surgical outcomes such as mortality, readmissions, complications and failure to rescue (FTR) using claims data has not been established. Objective Compare diagnosis- and prescription-based comorbidity scores for predicting surgical outcomes. Methods We used 100% Texas Medicare data (2006–2011) and included patients undergoing coronary artery bypass grafting (CABG), pulmonary lobectomy, endovascular repair of abdominal aortic aneurysm, open repair of abdominal aortic aneurysm, colectomy, and hip replacement (N=39,616). The ability of diagnosis-based (Charlson comorbidity score, Elixhauser comorbidity score, Combined Comorbidity Score, Centers for Medicare & Medicaid Services-Hierarchical Condition Categories [CMS-HCC]) vs. prescription-based chronic disease (CDS) score in predicting 30-day mortality, 1-year mortality, 30-day readmission, complications, and FTR were compared using c-statistics (c) and integrated discrimination improvement (IDI). Results The overall 30-day mortality was 5.8%, 1-year mortality was 17.7%, 30-day readmission was 14.1%, complication rate was 39.7%, and FTR was 14.5%. CMS-HCC performed the best in predicting surgical outcomes (30-day mortality, c=0.791, IDI=4.59%; 1-year mortality, c=0.798, IDI=9.60%; 30-day readmission, c=0.630, IDI=1.27%; complications, c=0.766, IDI=9.37%; FTR, c=0.811, IDI=5.24%) followed by Elixhauser comorbidity index/disease categories (30-day mortality, c=0.750, IDI=2.37%; 1-year mortality, c=0.755, IDI=5.82%; 30-day readmission, c=0.629, IDI=1.43%; complications, c=0.730, IDI=3.99%; FTR, c=0.749, IDI=2.17%). Addition of prescription-based scores to diagnosis-based scores did not improve performance. Conclusions The CMS-HCC had superior performance in predicting surgical outcomes. Prescription-based scores, alone or in addition to diagnosis-based scores, were not better than any diagnosis-based scoring system.

BACKGROUND Spontaneous peritonitis is an infection of ascitic fluid without a known intra-abdominal source of infection. spontaneous fungal peritonitis (SFP) is a potentially fatal complication of decompensated cirrhosis, defined as fungal infection of ascitic fluid in the presence of ascitic neutrophil count of greater than 250 cells/mL. AIM To determine the prevalence of fungal pathogens, management and outcomes (mortality) of SFP in critically ill cirrhotic patients. METHODS Studies were identified using PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Scopus databases until February 2019. Inclusion criteria included intervention trials and observation studies describing the association between SFP and cirrhosis. The primary outcome was in-hospital, 1-mo, and 6-mo mortality rates of SFP in cirrhotic patients. Secondary outcomes were fungal microorganisms identified and in hospital management by anti-fungal medications. The National Heart, Lung and Blood Institute quality assessment tools were used to assess internal validity and risk of bias for each included study. RESULTS Six observational studies were included in this systematic review. The overall quality of included studies was good. A meta-analysis of results could not be performed because of differences in reporting of outcomes and heterogeneity of the included studies. There were 82 patients with SFP described across all the included studies. Candida species, predominantly Candida albicans was the fungal pathogen in majority of the cases (48%-81.8%) followed by Candida krusei (15%-25%) and Candida glabrata (6.66%-20%). Cryptococcus neoformans (53.3%) was the other major fungal pathogen. Antifungal therapy in SFP patients was utilized in 33.3% to 81.8% cases. The prevalence of in hospital mortality ranged from 33.3% to 100%, whereas 1-mo mortality ranged between 50% to 73.3%. CONCLUSION This systematic review suggests that SFP in end stage liver disease patient is associated with high mortality both in the hospital and at 1-mo, and that antifungal therapy is currently underutilized.

When DRG migration rate was extrapolated to the entire at risk population, the results were an increase of Centers for Medicare and Medicaid Services (CMS) cost by $98 million, hospital cost by $418 million, and excess hospital days equaling 68,669 days. These negative outcomes represent potentially unnecessary variations in the processes of care, and therefore a unique economic concept defining inefficient surgical care.

INTRODUCTION While there are many reported advantages to laparoscopic surgery compared to open surgery, the impact of a laparoscopic approach on postoperative morbidity in obese patients undergoing rectal surgery has not been studied. Our goal was to determine if obese patients undergoing laparoscopic rectal surgery experienced the same benefits as non-obese patients. METHODS We identified patients undergoing rectal resections using the National Surgical Quality Improvement Project (NSQIP) participant use data file. We performed multivariable analyses to determine the independent association between laparoscopy and postoperative complications. RESULTS 26,437 patients underwent rectal resection. The mean age was 58.5 years, 32.6% were obese, and 47.2% had cancer. Laparoscopic procedures were slightly less common in obese patients compared to non-obese patients (36.0% vs. 38.2%, p=0.0006). In unadjusted analyses, complications were lower with the laparoscopic approach in both obese (18.9% vs. 32.4%, p<0.0001) and non-obese (15.6% vs. 25.3%, p<0.0001) patients. In a multivariable analysis controlling for potential confounders, the risk of postoperative complications increased as the degree of obesity worsened. The likelihood of experiencing a postoperative complication increased by 25%, 45%, and 75% for obese class I, obese class II, and obese class III patients respectively. A laparoscopic approach was associated with a 40% decreased odds of a postoperative complication for all patients (OR 0.60, 95% CI 0.56-0.64). CONCLUSION Laparoscopic rectal surgery is associated with fewer complications when compared to open rectal surgery in both obese and non-obese patients. Obesity was an independent risk factor for postoperative complications. In appropriately selected patients, rectal surgery outcomes may be improved with a minimally invasive approach.

Laparoscopic colectomy is superior to an open approach, with fewer 30-day readmissions, fewer discharges to SNF/ICF or home health, shorter hospital stays, and less overall cost; younger patients benefit more than older patients.