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An aging surgical population places an increasing burden on surgeons to accurately risk stratify and counsel patients. Preoperative frailty assessments are a promising new modality to better evaluate patients but can often be time consuming. Data regarding frailty and hepatectomy outcomes have not been published to date. Using the National Surgical Quality Improvement Project database, we examined hepatectomy patients 2005 to 11 and correlated frailty scores with outcomes of major morbidity, mortality, and extended length of stay, using a previously validated modified frailty index score. Frailty was compared against age, American Society of Anesthesiologists class, and other common risk variables. Multivariate regression identified frailty as the strongest predictor of Clavien 4 complications (OR = 40.0, 95% CI = 15.2 to 105.0), and mortality (OR = 26.4, 95% CI = 7.7 to 88.2). As the frailty score increased, there was a statistically significant increase in Clavien 4 complications, mortality, and extended length of stay (P < .001 for all). Frailty is a significant factor in morbidity and mortality after hepatectomy. Use of the modified frailty index allows for feasibility of data collection in a busy clinical setting. •We examined frailty and outcomes in 10,300 hepatectomies from the NSQIP database.•Frailty contributes to serious morbidity and mortality after hepatectomy.•Frailty is more significant than other commonly assessed risk factors.•A modified frailty index simplifies assessment in a clinical setting.

Preoperative steroid use has been associated with increased postoperative complications. We sought to establish these risks using data from the National Surgical Quality Improvement Program (NSQIP). NSQIP public use files from 2005 to 2008 were analyzed for preoperative steroid use and postoperative adverse events. Of 635,265 patients identified, 20,434 (3.2%) used steroids preoperatively. Superficial surgical site infections (SSI) increased from 2.9% to 5% using steroids (odds ratio, 1.724). Deep SSIs increased from .8% to 1.8% (odds ratio, 2.353). Organ/space SSIs and dehiscence increased 2 to 3-fold with steroid use (odds ratios, 2.469 and 3.338, respectively). Mortality increased almost 4-fold (1.6% to 6.0%; odds ratio, 3.920). All results were significant ( P < .001). Previous concerns related to surgical risks in patients on chronic steroid regimens appear valid. These results may assist in counceling patients regarding the increased risk of surgery. They may also help the surgeon plan and modify the procedure if possible.

ObjectiveThe objective of this study is to assess the effects of social determinants of health (SDOH) and race-ethnicity on readmission and to investigate the potential for geospatial clustering of patients with a greater burden of SDOH that could lead to a higher risk of readmission.DesignA retrospective study of inpatients at five hospitals within Henry Ford Health (HFH) in Detroit, Michigan from November 2015 to December 2018 was conducted.SettingThis study used an adult inpatient registry created based on HFH electronic health record data as the data source. A subset of the data elements in the registry was collected for data analyses that included readmission index, race-ethnicity, six SDOH variables and demographics and clinical-related variables.ParticipantsThe cohort was composed of 248 810 admission patient encounters with 156 353 unique adult patients between the study time period. Encounters were excluded if they did not qualify as an index admission for all payors based on the Centers for Medicare and Medicaid Service definition.Main outcome measureThe primary outcome was 30-day all-cause readmission. This binary index was identified based on HFH internal data supplemented by external validated readmission data from the Michigan Health Information Network.ResultsRace-ethnicity and all SDOH were significantly associated with readmission. The effect of depression on readmission was dependent on race-ethnicity, with Hispanic patients having the strongest effect in comparison to either African Americans or non-Hispanic whites. Spatial analysis identified ZIP codes in the City of Detroit, Michigan, as over-represented for individuals with multiple SDOH.ConclusionsThere is a complex relationship between SDOH and race-ethnicity that must be taken into consideration when providing healthcare services. Insights from this study, which pinpoint the most vulnerable patients, could be leveraged to further improve existing models to predict risk of 30-day readmission for individuals in future work.

Elderly patients are thought to tolerate surgical complications poorly because of low physiologic reserve. The purpose of the study was to evaluate the differential effects of surgical harm in patients over 80 years old. Three years of data from a harm-reduction campaign were used to identify inpatient surgeries performed on patients older than 50. The rates of harm, death, cost, and length of stay (LOS) were analyzed using SPSS 21 (IBM, New York, NY). A total of 22,710 patients were identified. Rates of harm and mortality increased with increasing age. Harmed patients over age 80 had increased mortality (9.5% vs 7%), but lower cost, intensive care unit days, and LOS versus those aged 50 to 80. Linear regression showed increased cost with harm ($24,000) and decreased cost with age above 80 (−$7,000). In the elderly surgical population, there is more harm and harm events are associated with higher mortality rates, but less additional cost and LOS. Differing goals or aggressiveness of care may explain cost avoidance in the elderly.

Hyperbilirubinemia in intensive care unit (ICU) patients is common. We hypothesized that hyperbilirubinemia in the surgical ICU predisposes patients to infection. Patients with bilirubin ≤3 mg/dL were compared to patients with bilirubin >3 mg/dL. We then compared the low bilirubin patients to high bilirubin patients who developed infection after their hyperbilirubinemia. There were 1,620 infections in 5,712 patients with low bilirubin (28%), compared with 284 in 409 patients in the high bilirubin group (69%, P < .001). After removing the patients in whom hyperbilirubinemia developed after infection, we found infection in 156 of 281 remaining patients (56%, P < .001). This group had a 3-fold increased risk of infection compared with low bilirubin (odds ratio [OR] 3.17, 95% confidence interval [CI] 2.48–4.03, P < .001). There is an increased susceptibility to infection among jaundiced surgical ICU (SICU) patients that persists even when sepsis-related hyperbilirubinemia patients are excluded.

Health care systems are increasingly utilizing electronic medical record—associated patient portals to facilitate communication with patients and between providers and their patients. These patient portals are growing in recognition as potentially valuable research tools. While there is much information about the response rates and demographics of internet-based surveys as well as the demographics of patients who are portal members, not much is known about the response rate of internet-based surveys directed to a group of patient portal members or the demographics of which portal members respond to internet-based surveys issued within that specific population. The objective of these analyses was to determine the demographics of patient portal users who respond to an internet-based survey request. We hypothesized that respondents would more likely be: (1) older (65+), (2) European American, (3) married, (4) female, (5) college educated, (6) have higher medical care utilization, (7) have more comorbidities, and (8) have a private practice primary care physician (as opposed to a salaried group practice primary care physician). We found that our respondents tended to be older, of European geographic ancestry, and more frequent users of healthcare. While patient portal members are an easily identifiable and contactable group that are potentially valuable participants for research, it is important to understand that respondents to surveys solicited from this sampling frame may not be entirely representative. It will be important to develop strategies to more fully engage populations that represent the target population in order to increase overall and subgroup response rates.

BackgroundThe Agency for Healthcare Research and Quality uses Patient Safety Indicators (PSI) to gauge quality of care and patient safety in hospitals. PSI 90 is a weighted combination of several PSIs that primarily comprises perioperative events. This score can affect reimbursement through Medicare and hospital quality ratings. Minimally invasive surgery (MIS) has been shown to decrease adverse events and outcomes. We sought to evaluate individual PSI and PSI 90 outcomes of minimally invasive versus open colorectal surgeries using a large medical database from 5 hospitals.MethodsA health system administrative database including all inpatients from 5 acute care hospitals was queried based on ICD 10 PC codes for colon and rectal surgery procedures performed between January 2, 2018 and December 31, 2019. Surgeries were labeled as MIS (laparoscopic) or open colorectal resection surgery. Patient demographics, health information, and case characteristics were analyzed with respect to surgical approach and PSI events. Statistical relationships between surgical approach and PSI were investigated using univariate methods and multivariate logarithmic regression analysis. PSIs of interest were PSI 8, PSI 9 PSI 11, PSI 12, and PSI 13.ResultsThere were 1382 operations identified, with 861 (62%) being open and 521 (38%) being minimally invasive. Logistic modeling showed no significant difference between the 2 groups for PSI 3, 6, or 8 through 15.ConclusionUnderstanding PSI 90 and its components is important to enhance perioperative patient care and optimize reimbursement rates. We showed that MIS, despite providing known clinical benefits, may not affect scores in the PSI 90. Surgical approach may have little effect on PSIs, and other patient and system components that are more important to these outcome measures should be pursued.

The presence of nucleated red blood cells (NRBCs) has been identified as a poor prognostic indicator. We investigated the relationship of NRBC trends in patients with and without trauma. We retrospectively reviewed surgical intensive care unit admissions over 4 years, categorizing trauma and nontrauma patients and subdividing them into 3 groups: group A, all-zero NRBC; group B, positive NRBC value returning to zero; and group C, positive NRBC value that did not return to zero. We analyzed all groups for outcomes of length of stay and mortality. Group A was the largest and had the shortest length of stay and least mortality. Group C had the highest mortality rate. No statistical difference was observed with mortality. Any positive NRBC was associated with poor outcome, and increasing NRBC was associated with increasing mortality. Trends in NRBC values showed that returning to zero was protective.

Background Despite rigorous health screening in astronaut crews, there are a number of conditions that may occur during long duration, exploration class spaceflight. The risk of abdominal conditions requiring surgical intervention is not clear, yet submarine and polar base experiences suggest contingency planning is warranted. While radio communication time delay is only 2 s to the international space station (ISS), a potential Mars mission would necessitate time delays of about 15 min. We sought to demonstrate the feasibility of remote expert guidance of diagnostic ultrasound followed by laparoscopic appendectomy in a simulated Mars environment. Methods Research was deemed exempt by the institutional review board. A simulated Mars research environment was utilized on Devon Island in the Canadian Arctic. Electronic communications including audio and video were established between the Arctic base and Henry Ford Hospital serving as Mission Control and incorporated the 15-min communications lag into all communication. Ultrasound and laparoscopic capabilities were integrated into communications for remote guidance. Remote guidance methods and technology utilized has been previously published in communication with the ISS. A simulated scenario involving a young female astronaut developing right lower quadrant pain was developed and utilized for this demonstration. An anatomical appendectomy model was utilized for the ultrasound and laparoscopic portions. Reference aids describing background technical aspects were developed. A set of confirmation milestones was used to generate a hard stop and mandated remote review. Results The simulated appendectomy was successfully pursued on the first attempt with no delays or untoward events. Reference aids were appropriate for non-surgical personnel and hard stops for milestones with remote approval and go ahead were shown to be feasible. The appendicitis was appropriately diagnosed utilizing remote guidance of ultrasonography and the appendix removed laparoscopically using stapled technique with remote guidance as well. Conclusions We report a successful remote guidance demonstration from a simulated mars environment with clinical control from a terrestrial base utilizing appropriate delay and consistent bandwidth and technology

In 2000, we implemented an evidence-based guideline in the surgical intensive care unit (SICU) using a transfusion threshold of hemoglobin <8 g/dL. We hypothesized that continual education on the transfusion protocol would decrease transfusions. We analyzed 2-month samples of admissions in even-numbered years from 1998 to 2006. Any infusion of packed red blood cells (PRBCs) was included. We analyzed data from 2,138 patients resulting in 5,130 transfusions. Thirty-six patients received >20 U of blood. The only difference between groups occurred in 2006 when renal failure increased. Transfusions decreased from 3.2 ± 0.34 (SE) to 1.7 ± 0.2. The number of patients who received blood also decreased. Mortality and length of stay (LOS) were not different among the groups. Every unit of blood transfused increased the mortality risk by 14%. Implementation of an evidence-based transfusion guideline reduced the number of infused units and patients transfused without an increase in mortality.