Defining Rates and Risk Factors for Readmissions Following Emergency General Surgery

Havens, Joaquim M.; Olufajo, Olubode A.; Cooper, Zara; Haider, Adil H.; Shah, Adil A.; Salim, Ali

doi:10.1001/jamasurg.2015.4056

Cited by 135 publications

(140 citation statements)

References 39 publications

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“…Hospital readmission is increasingly being used by third party payers as a marker of health care resource use and overall quality, and there is growing interest in identifying factors that contribute to the need for readmission. 15 As our study demonstrates, however, the factors that have the greatest impact on hospital readmission may not be the same factors that pose the largest burden on early postoperative patient outcomes. As a result, initiatives designed to reduce post-EGS mortality may not substantially affect post-EGS readmission, and vice versa.…”

Section: Discussionmentioning

confidence: 71%

“…Second, the occurrence of postoperative complications is strongly associated with the risk of subsequent death and with the generation of considerable costs of care and excess health care resource use. 11–15 A reduction in the frequency of complications in the EGS population would therefore be anticipated to result in significant savings, both in terms of patient lives and health care expenditures. Finally, the time-sensitive nature of EGS disease will generally preclude reliance on traditional approaches to surgical quality improvement, such as preoperative risk factor modification.…”

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confidence: 99%

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Which Complications Matter Most? Prioritizing Quality Improvement in Emergency General Surgery

Scarborough

Schumacher

Pappas

et al. 2016

Journal of the American College of Surgeons

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BACKGROUND Because preoperative risk factor modification is generally not possible in the emergency setting, complication prevention represents an important focus for quality improvement in emergency general surgery (EGS). The objective of our study was to determine the overall impact that specific postoperative complications have in this patient population. STUDY DESIGN Our study sample consisted of patients from the 2012–2013 ACS-NSQIP database who underwent an EGS procedure. We used population attributable fractions (PAFs) to estimate the overall impact that each of 8 specific complications had on 30-day physiologic and resource use outcomes in our study population. The PAF represents the percentage reduction in a given outcome that would be anticipated if a complication were able to be completely prevented in our study population. Both unadjusted and risk-adjusted PAFs were calculated. RESULTS There were 79,183 patients included for analysis. The most common complications in these patients were bleeding (6.2%), incisional surgical site infection (SSI) (3.4%), pneumonia (2.7%), and organ/space SSI (2.6%). Bleeding was the complication with the greatest overall impact on mortality and end-organ dysfunction, demonstrating an adjusted PAF of 10.7% (95% CI 8.2%,13.1%, p < 0.001) and 15.9% (95% CI 13.9%, 16.7%, p < 0.001) for these respective outcomes. The only other complication with a sizeable impact on these outcomes was pneumonia (adjusted PAF of 7.9% for mortality and 13.2% for pneumonia). In contrast, complications such as urinary tract infection, venous thromboembolism, myocardial infarction, and incisional SSI had negligible impacts on these outcomes. CONCLUSIONS Our study provides a framework for the development of high-value quality initiatives in EGS.

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Section: Discussionmentioning

confidence: 71%

mentioning

confidence: 99%

Which Complications Matter Most? Prioritizing Quality Improvement in Emergency General Surgery

Scarborough

Schumacher

Pappas

et al. 2016

Journal of the American College of Surgeons

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“…In addition, PLT transfusion is indispensable in patients with congenital PLT disorders, disturbed hematopoiesis, or after myeloablative chemotherapy preceding hematopoietical stem cell transplantation (1)(2)(3). Many of these conditions are accompanied by an increased risk for infection related to trauma itself or neutropenia (4)(5)(6)(7). PLT express HLA class I molecules (8,9).…”

mentioning

confidence: 99%

Platelet-Derived Ectosomes Reduce NK Cell Function

Sadallah

Schmied

Eken

et al. 2016

The Journal of Immunology

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Platelet (PLT) transfusions are potentially life saving for individuals with low PLT numbers; however, previous work revealed that PLT transfusions are associated with increased infection risk. During storage, PLT intended for transfusion continuously shed ectosomes (Ecto) from their surface, which express immunomodulatory molecules like phosphatidylserine or TGF-β1. Recently, PLT-Ecto were shown to reduce proinflammatory cytokine release by macrophages and to favor the differentiation of naive T cells toward regulatory T cells. Whether PLT-Ecto modify NK cells remains unclear. We exposed purified NK cells and full PBMCs from healthy donors to PLT-Ecto. We found a reduced expression of several activating surface receptors (NKG2D, NKp30, and DNAM-1) and decreased NK cell function, as measured by CD107a expression and IFN-γ production. Pretreatment of PLT-Ecto with anti–TGF-β1 neutralizing Ab restored surface receptor expression and NK cell function. We further observed a TGF-β1–mediated upregulation of miR-183, which, in turn, reduced DAP12, an important protein for stabilization and downstream signaling of several activating NK cell receptors. Again, these effects could antagonized, in part, when PLT-Ecto were preincubated with anti–TGF-β1 Ab. Erythrocyte Ecto did not affect NK cells. Polymorphonuclear cell Ecto expressed MHC class I and inhibited NK cell function. In addition, they induced the secretion of TGF-β1 by NK cells, which participated in an auto/paracrine manner in the suppressive activity of polymorphonuclear cell–derived Ecto. In sum, our study showed that PLT-Ecto could inhibit NK cell effector function in a TGF-β1–dependent manner, suggesting that recipients of PLT transfusions may experience reduced NK cell function.

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“…In 2015, a study was carried out using the California State Inpatient Database that showed that 5.9% of EGS patients were readmitted within 30 days of discharge with higher rates of readmission in patients on public insurance and those with higher baseline comorbidity status, longer lengths of index hospital stay, and discharge dispositions other than home 16. Of those patients, nearly one in five were readmitted to a different hospital than where their surgery was performed, which was termed “care discontinuity” 16. In 2016, Medicare inpatient claims data were used to show that care discontinuity increased the odds of death in EGS patients by 16% 11.…”

Section: The Presentmentioning

confidence: 99%

“…An emphasis on patient‐reported outcome measures is particularly important in a cohort proven to be at high risk and with less resources 16. Expansion of collection of health‐care data to include patient reported outcomes can assist in obtaining a better picture of the EGS patient group.…”

Section: The Futurementioning

confidence: 99%

Past, present, and future of Emergency General Surgery in the USA

Lyu

Najjar

Havens

2018

Acute Medicine & Surgery

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Emergency General Surgery (EGS) patients represent a unique group of acutely ill surgical patients at high risk for death and complications. Since the inception of EGS as a surgical subspecialty in the early 2000s, there have been significant developments to further define the scope of EGS as well as to advance data collection, performance measurement, and quality improvement. This includes defining the EGS cohort by diagnosis and procedure and by overall burden, benchmarking of EGS outcomes, and creation of quality improvement programs aimed at reducing the excess morbidity and mortality associated with EGS. Going forward there exists a need for a more modern approach to quality improvement. This may include the creation of an EGS data registry, the use of electronic medical records data, wearable device technology, and a focus on patient reported outcomes.

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Defining Rates and Risk Factors for Readmissions Following Emergency General Surgery

Cited by 135 publications

References 39 publications

Which Complications Matter Most? Prioritizing Quality Improvement in Emergency General Surgery

Which Complications Matter Most? Prioritizing Quality Improvement in Emergency General Surgery

Platelet-Derived Ectosomes Reduce NK Cell Function

Past, present, and future of Emergency General Surgery in the USA

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