Weekend hospitalisations and post-operative complications following urgent surgery for ulcerative colitis and Crohn's disease
ABSTRACT BACKGROUND: There is increasing complexity in the management of patients with acute severe exacerbation of inflammatory bowel disease [IBD; Crohn's disease (CD), ulcerative colitis (UC)] with frequent requirement for urgent surgery. AIM: To determine whether a weekend effect exists for IBD care in the United States. METHODS: We used data from the Nationwide Inpatient Sample (NIS) 2007, the largest all-payer hospitalisation database in the United States. Discharges with a diagnosis of CD or UC who underwent urgent intestinal surgery within 2 days of hospitalisation were identified using the appropriate ICD-9 codes. The independent effect of admission on a weekend was examined using multivariate logistic regression adjusting for potential confounders. RESULTS: Our study included 7,112 urgent intestinal surgeries in IBD patients, 21% of which occurred following weekend admissions. There was no difference in disease severity between weekend and weekday admissions. Post-operative complications were more common following weekend than weekday hospitalisations in UC [odds ratio (OR) 1.71, 95% confidence interval (CI) 1.01-2.90]. The most common post-operative complication was post-operative infections (Weekend 30% vs. weekday 20%, P = 0.04). The most striking difference between weekend and weekday hospitalisations was noted for needing repeat laparotomy (OR 11.5), mechanical wound complications (OR 10.03) and pulmonary complications (OR 2.22). In contrast, occurrence of any post-operative complication in CD was similar between weekday and weekend admissions. CONCLUSION: Patients with UC hospitalised on a weekend undergoing urgent surgery within 2 days have an increased risk for post-operative complications, in particular mechanical wound complications, need for repeat laparotomy and post-operative infections.
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ABSTRACT: Initiation of dialysis on Sunday is limited by constraints that do not exist on other days of the week, which may lead to triaging of dialysis therapy. The study hypothesis was that patients with AKI on a Sunday would sustain higher mortality rates. Study participants (n=4970) were part of the retrospective University of Pennsylvania Health AKI cohort, which is composed of patients with severe inpatient AKI (characterized by a doubling of admission creatinine) who were hospitalized from January 1, 2004, to August 31, 2010. Patient-days (n=15,995) were included if the patient had AKI severity of Acute Kidney Injury Network (AKIN) stage 2 or greater and had not yet begun receiving dialysis. The association of day of the week and inpatient mortality was assessed with logistic regression of data updated daily, using robust variance estimators. The rate (95% confidence interval [CI]) of initiation of dialysis on Sunday was 2.5 (1.8 to 3.1) per 100 patient-days, compared with 3.8 (3.5 to 4.1) per 100 patient-days on other days of the week (P=0.001). Inpatient mortality (95% CI) among patients with severe AKI present on a Sunday was 30% (28% to 32%), compared with 31% (31% to 32%) on other days of the week (P=0.08). Inpatient mortality among patients who initiated dialysis on Sunday was 65% (52% to 79%), compared with 65% (61% to 70%) among those who initiated dialysis from Tuesday through Saturday (P=0.79). Patients who initiated dialysis on Monday had a lower mortality than those who initiated it on another day of the week (52% [40% to 64%] versus 65% [61% to 70%]; P=0.03). Despite a lower frequency of dialysis, patients with severe AKI on Sunday have mortality similar to that of patients with severe AKI on other days of the week.Clinical Journal of the American Society of Nephrology 08/2013; DOI:10.2215/CJN.03540413 · 5.25 Impact Factor
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ABSTRACT: OBJECTIVES:Endoscopic retrograde cholangiopancreatography (ERCP) performed on the weekend requires significant effort from the endoscopist, nursing staff, and anesthesia services. These factors often result in delaying the procedure until the following Monday. No data exist on whether performing weekend ERCP reduces length of stay (LOS) and total cost to justify the additional physician and nursing burden.METHODS:In this single tertiary academic center, institutional review board-approved study, we retrospectively reviewed all hospitalized patients in whom an ERCP had been completed from May 2010 to September 2011. Demographic and clinical information, procedure details as well as total hospitalization charges (USD) were compared between patients who had an ERCP either on the weekend or weekday holiday (WE ERCP) or Monday (MON ERCP). Statistical comparisons were made using χ(2) and Fischer's exact test. A logistic regression model adjusted for propensity scores (PSs) was used to estimate the risk in prolonged LOS and high total charges associated with WE ERCPs vs. MON ERCPs.RESULTS:A total of 1,114 ERCP's were performed during the time period, 123 of which met inclusion criteria (52 WE, 71 MON). Mean patient age was 56.3±16.7 years (54.5% female, 60.2% Caucasian). There were no significant demographic differences between the two groups. The most common procedure indications were choledocholithiasis (34.9%) and elevated liver enzymes after liver transplantation (25.2%). The analysis showed a significantly decreased LOS (P=0.010) and a trend towards decreased cost (P=0.050) associated with WE ERCP. In the multivariate analysis adjusted for PS, WE ERCP had a significantly decreased odds ratio of LOS>3 days (odds ratio: 0.37 (0.16-0.85); P=0.019).CONCLUSIONS:We demonstrated a significant decrease in LOS and a trend towards decrease in charges in patients who underwent weekend ERCP compared with delaying ERCP until Monday. Thus, health-care organizations should consider removing barriers to weekend inpatient ERCPs.Am J Gastroenterol advance online publication, 22 October 2013; doi:10.1038/ajg.2013.362.The American Journal of Gastroenterology 10/2013; 109(4). DOI:10.1038/ajg.2013.362 · 9.21 Impact Factor
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ABSTRACT: Decisions between medical and surgical management of Crohn's disease (CD) incorporate risk assessments for potential complications of each therapy. Analytic morphomics is a novel method of image analysis providing quantifiable measurements of body tissue composition, characterizing body fat more comprehensively than body mass index alone. The aim of this study was to determine the risk factors associated with postoperative complications in CD, incorporating fat composition analysis using analytic morphomics. We performed a retrospective review of adults undergoing bowel resection for CD between 2004 and 2011 at a single center. Computed tomography obtained within 30 days prior to surgery underwent morphomic analysis for fat characterization. Postoperative infectious complications were defined as the need for a postoperative abdominal drain, intravenous antibiotics, or reoperation within 30 days. Bivariate and multivariate analyses using logistic regression were used to generate a prediction model of infectious complications. A total of 269 subjects met selection criteria; 27% incurred postoperative infectious complications. Bivariate analysis showed hemoglobin, albumin, surgical urgency, high-dose prednisone use, and subcutaneous-to-visceral fat volume distribution as predictors of complications. Body mass index, anti-tumor necrosis factor alpha therapies, and immunomodulator use were not predictors of complication. Multivariate modeling demonstrated a c-statistic of 0.77 and a negative predictive value of 81.1% with surgical urgency (odds ratio = 2.78; 95% confidence interval, 1.46-6.02; P = 0.004), subcutaneous-to-visceral fat distribution (odds ratio = 2.01; 95% confidence interval, 1.20-3.19; P = 0.006), and hemoglobin (odds ratio = 0.69; 95% confidence interval, 0.55-0.85; P = 0.001) as predictors of infectious complication. Fat subtype and distribution are predictive of postoperative infectious complications after bowel resection for CD. Analytic morphomics provides additional body composition detail not captured by body mass index.Inflammatory Bowel Diseases 03/2015; DOI:10.1097/MIB.0000000000000360 · 5.48 Impact Factor