United States

Background:
Survey of procedures performed across all surgical subspecialties at the Iowa City VAMC in FY2018 showed that the rate of 30-day period surgical site infections (SSI) was significantly higher than that of national average. Average cost saving from single deep or organ space SSI and single superficial SSI are approximately $34,407 and $1,000, respectively. SSI places significant financial burden to the healthcare systems and complicates the course of postoperative recovery. 

Methods:
Previously, all patients undergoing surgery at the Iowa City VAMC underwent Chlorohexidine Gluconate (CHG) bath prior to surgery. A new surgical site infection prevention protocol (SSIPP) involving 2% CHG cloths for skin, Povidone Iodine nasal swab, and 0.12% CHG mouth rinse was implemented in October of 2019 (Figure 1,2)). All eligible cases were reviewed since the implementation of the SSIPP. All recorded SSI were categorized into deep/organ space SSI or superficial SSI. This was compared with the rate of SSI recorded before the SSIPP implementation and cost savings were estimated accordingly.

Results:
From 10/01/2019 to 09/30/2020 a total of 885 eligible cases were reviewed, revealing a total of 3 deep/organ space SSI. This is significantly lower than 15 deep/organ space SSI recorded from 01/01/2018 to 12/31/2018 out of 1042 cases (p=0.016). However, rate of superficial SSI from 10/01/2019 to 03/30/2020 was significantly different from that of 2018 (p=0.80).

Compared to 2018, estimated total cost savings from reductions in deep/organ space SSI ($516,105 vs $258,052) and superficial SSI ($9,000 vs $6,000) approximates to $415,884.

Conclusion
SSI is a known surgical complication that places significant financial burden on healthcare systems and puts patients at greater risk of postoperative mortality and morbidity. Preoperative infection prevention protocol involving CHG cloths, Povidone Iodine swab, and CHG mouth rinse has significantly decreased the overall rate of SSI and those that involve deep/organ space SSI. This approximates to total cost savings of $415,884 at no cost to the patient.


AMA Research Challenge 2022

Preoperative Infection Prevention Protocol to Reduce Rate of Surgical Site Infections

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Charles Lopresto, DO

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poster

Introduction: Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, the conventional multimorbidity definition (≥2 comorbidities) labels the vast majority of elderly patients as multimorbid, limiting its clinical benefit. We developed and validated a better surgical specialty-specific multimorbidity definition based on distinct comorbidity combinations called Qualifying Comorbidity Sets (QCSs).

Methods: We used Medicare claims data for patients aged 66-90 years hospitalized for general (GS), orthopedic (OS), or vascular surgery (VS). Using 2016-2017 data, we identified all comorbidity combinations associated with a double-or-greater risk of 30-day mortality compared to the overall population undergoing the same procedure; these were defined as QCSs. We applied these QCSs to 2018-2019 data (GS=462,904 patients, OS=1,493,999, VS=301,336) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbid patients treated at better-resourced (based on nursing resources, surgical volume, teaching status) vs. other hospitals had differential outcomes using multivariate matching.

Results: Compared to the conventional multimorbidity definition, the QCS-based definition labeled fewer patients as multimorbid: GS=85.0% vs. 55.9% (p<0.0001); OS=66.6% vs. 40.2% (p<0.0001); VS=96.2% vs. 52.7% (p<0.0001) (Table 1). Thirty-day mortality was higher by the QCS-based definition: GS=3.96% [conventional] vs. 5.64% [QCS-based] (p<0.0001); OS=1.13% vs. 1.68% (p<0.0001); VS=4.43% vs. 7.00% (p<0.0001). Better-resourced hospitals offered larger mortality benefits for multimorbid vs. non-multimorbid GS and OS patients (GS absolute risk reduction difference-in-difference=-0.94% [95% CI -1.24%,-0.63%], p<0.0001; OS difference-in-difference=-0.20% [95% CI -0.29%,-0.10%], p<0.0001).

Conclusion: Our QCS-based multimorbidity definition identifies a more specific, higher risk pool of patients compared to the conventional definition, allowing for better clinical decision-making.

Redefining Multimorbidity in Older Surgical Patients

Social determinants of health (SDOH) studies have underscored the impact of the local environment on both cancer outcomes and cardiovascular health. Adolescent and young adult (AYA) lymphoma survivors are commonly treated with cardiotoxic treatments that increase risk of poor cardiovascular outcomes. Thus, investigations of neighborhood-level measures and cardiovascular burden in diverse AYA lymphoma populations may provide insight into mediators of disparities in AYA lymphoma survivors.

This study utilizes a multi-ethnic cohort of AYA lymphoma survivors (N=353), diagnosed between ages 15-39, seen at MD Anderson Cancer Center. Clinical data abstraction for demographics, treatment, and follow-up information was completed. Follow-up data includes cardiovascular-related variables, such as BMI at baseline and last follow-up, diagnoses of hypertension, hyperlipidemia, heart failure and other cardiovascular diseases, and treatment with cardiovascular medications. Zip codes obtained from the medical record were used to query the U.S. Census Bureau to gather zip-code tabulation areas (ZCTA). Each ZCTA was linked with their associated Area Deprivation Index (ADI) values from the Public Health Neighborhood Atlas (University of Wisconsin). Clinical data and ADI values were evaluated to identify differences in poor cardiovascular burden by ADI and by ethnic group. 

The cohort includes 275 (77.9%) non-Hispanic white, 29 (8.2%) non-Hispanic Black, and 49 (13.9%) Hispanic cancer survivors (2+ years from diagnosis). The mean ADI value was 46.4 for the non-Hispanic whites, 58.2 for the non-Hispanic Blacks, and 55.5 for the Hispanic population. In total, 276 (78.2%) of the population was diagnosed with Hodgkin lymphoma and 77 (21.8%) with non-Hodgkin lymphoma. Based on the survivors with available clinical data, 34 (64.2%) had a cardiovascular disease (CVD) diagnosis and 43 (71.7%) were taking cardiac medications at follow-up. 

Differences in ADI between AYA lymphoma survivors by self-identified race/ethnicity were observed that suggest non-White AYA survivors experience higher burdens of poor SDOH compared their White AYA counterparts. Patients with a diagnosis of CVD and patients taking cardiac medications had higher ADI levels than those without, significantly so regarding cardiac medications. Survival of the multi-ethnic cohort by ADI quartiles was not significantly different, but when analyzed by highest versus lowest quartile some disadvantage was evident. Further analysis is needed to elucidate this relationship and provide sufficient evidence for potential social interventions.

Investigating the Impact of Neighborhood Deprivation Level on Cardiovascular Burden in Adolescent and Young Adult Lymphoma Survivors

We present a case of cutaneous scalp metastasis of retroperitoneal leiomyosarcoma. The patient in this case has an initial complaint of left upper quadrant pain, unintentional weight loss, fatigue, and night sweats. On initial physical exam he was found to have two right sided scalp nodules. The patient underwent a series of tests which resulted in a diagnosis of leiomyosarcoma of the retroperitoneum with metastasis to the right sided cutaneous scalp. Leiomyosarcoma is a rare malignancy of smooth muscle cells. It most commonly arises from uterine tissue but other primary locations include other gynecologic tissue, gastrointestinal, somatic soft tissue, and in the case of this patient, retroperitoneal. As with other sarcomas, metastasis likely occurs via hematogenous route. The literature on scalp metastasis of leiomyosarcoma is limited to case reports. To the best of our knowledge, only 4 other reports have been documented of retroperitoneal leiomyosarcoma metastasis to the cutaneous scalp have been identified. In one of these cases, metastasis to many other sites were found as well including lungs, hip, and thigh. Interestingly, in the case we present, no other metastasis besides the cutaneous scalp has been found. Our case serves to highlight the importance of a high index of clinical suspicion when caring for these patients. A full head to toe physical exam should be performed regularly and cutaneous nodules should be biopsied in order to assess for metastasis.

Metastasis of retroperitoneal leiomyosarcoma to the cutaneous scalp

Background: Frailty is a spectrum describing a demographic more likely to experience adverse events such as falls, disability, and hospital admission. The Modified Frailty Index (mFI) is a method of quantifying frailty, predicting increased risk of 30-day readmission. Though assessing risk of 30-day readmission is important, 44.7% of posterior lumbar decompression surgery readmissions occurred beyond 30 days. Therefore, a predictive model accounting for readmission within 90 days post-operatively will be more useful for this procedure.
Methods: This is a retrospective study on patient mFI and 90-day readmission for lumbar interbody fusion procedures involving two or more vertebral levels. Patients filled out an 11-point questionnaire derived from mFI prior to XLIF, OLIF, PLIF, TLIF, or ALIF surgery. mFI score and readmission data will be collected between the dates of January 2019 and December 2021. Next, associations will be assessed using Spearman’s rank-order correlation and ROC curves to determine the range of scores associated with readmission within 90 days.
Results: The purpose of this project is to assess whether a patient questionnaire format of the 11-point mFI can be used to predict risk of 90-day readmission for elderly patients undergoing multi-level lumbar interbody fusions. We expect for there to be a positive correlation between mFI and 90-day readmission.
Conclusion: The frailty questionnaire will provide a more time efficient alternative to mFI-11. The ability to calculate risk for 90-day readmission will more accurately assess the patient procedural risk. This will improve pre-operative counseling and may be helpful in reducing hospital length of stay while keeping the emotional interests of patients in mind.

Questionnaire Format of the Modified Frailty Index as a Predictor of 90-Day Readmission in Multi-Level Lumbar Interbody Fusion Patients

Background: Sterilization is an effective form of contraception with approximately 18.6% of women aged 15-49 years relying on this method, however only 39-57% of women who request this procedure prenatally ultimately undergo postpartum sterilization. The implications for incomplete but desired postpartum sterilization procedures negatively impact the health of women. At Penn State Hershey Medical Center (PSHMC), immediate postpartum sterilization after vaginal delivery is not standard practice, so a root cause analysis was done to identify existing barriers to postpartum sterilization after vaginal delivery at PSHMC.
Methods: Voluntary one-on-one qualitative interviews were conducted with a multidisciplinary group of stakeholders involved in performing postpartum sterilization. Stakeholders consisted of women’s health attendings, family and community medicine attendings, ob-gyn residents, anesthesiologists, and nursing leadership with the goal of obtaining a comprehensive understanding of this issue.
Results: Participants were asked standardized questions that were selected according to participant role in the postpartum sterilization process. Barriers identified were found to be either logistic and/or cultural. A root-cause analysis in the form of a fishbone model was performed to identify barriers and create targeted solutions for the future.
Conclusion: Due to the high rates of short-interval pregnancy, dissatisfaction, and associated health consequences, interview participants agreed that postpartum sterilization was an important procedure that patients should be able to obtain. It was also identified that the current model at PSHMC does not adequately provide this service to women who desire it. A sample standard operating procedure was created to begin formulating a framework to help increase the rate of postpartum sterilization to 1 per month at PSHMC, with cyclic re-evaluation.

A Root Cause Analysis of Logistical and Cultural Barriers to Postpartum Sterilization After Vaginal Delivery at a Tertiary Medical Center

Background:
Placenta accreta spectrum (PAS) refers to a disease of morbidly adherent trophoblastic tissue invading into the myometrium of the gravid uterus. The incidence of PAS has been rapidly increasing in recent years. Risk factors include previous uterine surgery, including cesarean delivery, and placenta previa. Patients with antenatally suspected PAS often undergo planned hysterectomy at cesarean delivery. Surgery for PAS is associated with significant maternal morbidity and mortality.
The 2018 joint consensus statement by the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) recommends the delivery timing for patients with PAS at 34 0/7–35 6/7 weeks of gestation as a Level 1A, strong recommendation based on high-quality evidence (Obstetric Care Consensus No.7, published 12/2018). The objective of this study was to examine the influence of their recommendation on delivery timing for PAS in real-world practice.

Methods:
This retrospective cohort study queried the Healthcare Utilization Cost and Utilization Project’s National Inpatient Sample. The study population was 5,655 patients with a diagnosis of both PAS and placenta previa who underwent cesarean delivery from 1/2016-12/2019. The study period was grouped into pre-consensus period (1/2016-12/2018) and post-consensus period (1/2019-12/2019). A quasi-experimental method with Difference-in-Difference analysis was fitted to examine the change in delivery timing, grouped as early-delivery (<34 weeks), recommended-delivery (34 0/7-35 6/7 weeks), and late-delivery (≥36 weeks).

Results:
At the cohort level, the number of late-delivery decreased by 15.1% and the number of early- delivery increased by 12.8% in the post-consensus period (P=0.001). When stratified by the severity of PAS, more prominent change occurred in severe forms of PAS (increta/percreta) with 37.7% relative-decrease in late-delivery and 13.2% relative-increase in recommended-delivery (P=0.002). When increta/percreta cases were further restricted to the elective admission cases, a marked shift in delivery timing occurred towards recommended-delivery from 32.2% to 51.3% (59.3% relative-increase) whereas late-delivery decreased significantly from 23.5% to <10% (78.3% relative-decrease; P<0.001).

Discussion:
This national-level assessment in the United States suggests that the delivery timing of patients with severe PAS is rapidly shifting to 34 0/7-35 6/7 weeks following the ACOG-SMFM consensus recommendation. Delivery beyond this recommended timing appears to rarely be planned in suspected placenta increta/percreta.
Key limitations of the study included unmeasured bias with a lack of information on exact shared decision-making discussion for the timing of surgery and preoperative diagnosis. Generalizability in different populations was not assessed.

Delivery timing of placenta accreta spectrum in the United States: Influence of a society-based recommendation

Abstract Title: Postpartum Contraception Decision Making Among Adolescent Mothers 

Background 

Adolescent mothers are more likely to experience short-interval repeat pregnancies than their non-adolescent counterparts, placing them at risk for both pregnancy-related morbidity and adverse socioeconomic outcomes. A previous study in our dyadic adolescent-mother baby medical home showed an association between long-acting contraception (LARC) use and decreased repeat pregnancy, but the reasons that adolescent mothers choose their subsequent contraceptive methods is not well elucidated. 

Methods 

We conducted semi-structured, in-depth phone interviews of 6 month postpartum adolescent women regarding contraceptive choice between 6/16/2020 and 11/16/2020. We recruited participants during their 6 week postpartum visit at the Young Mother’s Clinic, a dyadic primary care medical home located at the Children’s Hospital Colorado. All women who presented for their 6 week postpartum visit during the study period were invited to enroll. 

Twenty-one patient interviews were completed. Each interview was independently coded by two reviewers. All interview transcripts were coded to create a matrix outlining common themes related to contraceptive choice. These codes were then looked at further based on subgroup of contraceptive type and race/ethnicity. 

Results 

Multiple themes emerged upon performing rapid qualitative analysis. Most participants cited an inability to remember to take a daily pill as the reason they did not choose OCPs as their birth control method. Those who did not choose an IUD or implant cited invasiveness as reason for refusal. Participants chose methods other than Depo Provera because they felt that frequent appointments were inconvenient. Conversely, participants who chose the IUD/Implant cited its efficacy, convenience, and menses suppression as reasons for their decision. Those who chose Depo Provera favored its ease of use and menses suppression as well. Pregnancy plans were mentioned by several Hispanic/Latino participants as influencing selection of contraceptive methods, but never by non-Hispanic/Latino participants. Perceived efficacy, duration, and positive side effects were mentioned relatively more frequently by non-Hispanic/Latino participants as compared to Hispanic/Latino participants. 

Conclusion 

The data provided by this study highlights factors that influence adolescent mothers’ contraception decisions. This insight can be used to inform patient-centered contraception counseling specific to this population. 



Postpartum Contraception Decision Making Among Adolescent Mothers

Introduction: Multiple studies have demonstrated racial and ethnic disparities in pregnancy-related outcomes in the United States, and disparities in opioid pain management among different races and ethnicities have also been thoroughly documented. However, few studies have evaluated these disparities in the postpartum setting. We evaluated racial and ethnic disparities in postpartum opioid prescription at a high-volume tertiary care center before and after standardized opioid prescription guidelines were implemented. 

Methods: We conducted a retrospective study of all vaginal deliveries between August 14, 2017 and September 17, 2017, before guideline implementation, and between April 9, 2018 and May 4, 2018, after guideline implementation. We categorized patients into: Non-Hispanic Black, Non-Hispanic White, Hispanic, and Non-Hispanic Other. From medical records we collected demographic information, pain score data, inpatient opioid consumption, and oxycodone prescribed (in morphine milligram equivalents [MME]) upon discharge. 

Results: 560 patients were included, 282 pre-intervention and 278 post-intervention. Opioids administered in the first 24 hours of postpartum admission were 12.6 MME pre-intervention and 6.70 MME post-intervention, and the amount of opioids prescribed for home use were 125 MME pre-intervention and 28 MME post-intervention. There were no statistically significant differences in these measures between racial-ethnic groups before or after the intervention, and there were no significant differences between racial-ethnic groups in how often post-intervention guidelines were followed. 

Conclusion: Standardized prescription guidelines successfully decreased both inpatient and outpatient opioid consumption while maintaining equity among racial groups. Future studies may explore disparities in cesarean section patients, as these patients typically require larger amounts of opioids. 


Racial and ethnic disparities in postpartum opioid prescription

Background 

Near-term follow-up after evaluation in the emergency room for minor ophthalmic concerns can impose logistical challenges for patients and ophthalmology practices. While ophthalmic telemedicine has been used for screening and triage, its feasibility and safety for follow-up after presentation to the emergency department (ED) has not been reported. This study describes the initial results of a novel, newly-implemented Virtual Emergency Department Follow-Up (VEDFU) clinic at Mass Eye and Ear (MEE), a tertiary eye care center in Boston, MA. 

Methods

This was a retrospective, cross-sectional study of 145 clinical encounters from December 6, 2021 to July 1, 2022 in the VEDFU. Inclusion criteria included patients discharged from the MEE ED who required near-term follow-up for diagnoses deemed suitable for the virtual clinic, lived within Massachussets, and consented to virtual care. The primary outcome measures included mode of telemedicine encounter (video or phone call), missed appointment rate, documentation of clinical exam findings, clinical diagnoses, time interval between ED encounter and subsequent virtual follow-up, and referrals after initial telemedicine follow-up (stratified by urgency, subspecialty, and reason for follow-up). 

Results

A total of 145 visits scheduled in the EDFU were included. The mean age was 38.1 years (SD 14.2) and 78 (53.8%) were men. The no-show rate was 31.7%. The mean interval time between ED evaluation and virtual follow-up was 8.3 days (SD 3.9). Of the 99 completed visits, 15 were telephone calls and 84 were video visits. The most common diagnoses were conjunctivitis, chalazion, corneal abrasion, and subsequent encounter after removal of corneal foreign body. After virtual follow-up, 23 patients (23.2%) had subsequent referrals, and no patients returned to the ophthalmic ED.

Conclusion

A novel virtual follow-up program for ophthalmic ED patients enabled safe and timely telemedical re-examination for a range of minor indications without any patients necessitating return to the ED. To our knowledge, this is the first program of its kind and may serve as a model for other medical and surgical subspecialties with high rates of ED referrals, limited clinic availability, and diagnoses that can be managed safely through virtual visits. Larger, longitudinal studies are warranted to further validate ophthalmic telemedicine as an alternative avenue for post-acute near-term follow-up care.

Next from AMA Research Challenge 2022

Redefining Multimorbidity in Older Surgical Patients

Similar lecture

Redefining Multimorbidity in Older Surgical Patients