Background

Although significant racial disparities in the surgical management of lower extremity critical limb threatening ischemia have been previously reported, data on disparities in lower extremity acute limb ischemia are lacking.

Methods

The 2012-2018 National Inpatient Sample was queried for all adult hospitalizations for acute limb ischemia (N = 225,180). Hospital-specific observed-to-expected rates of major lower extremity amputation were tabulated. Multivariable logistic and linear models were developed to assess the impact of race on amputation and revascularization.

Results

Nonwhite race was associated with significantly increased odds of overall (adjusted odds ratio: 1.16, 95% confidence interval 1.06-1.28) and primary (adjusted odds ratio: 1.34, 95% confidence interval 1.17-1.53) major amputation, decreased odds of revascularization (adjusted odds ratio 0.79, 95% confidence interval 0.73-0.85), but decreased in-hospital mortality (adjusted odds ratio: 0.86, 95% confidence interval 0.74-0.99). The nonwhite group incurred increased adjusted index hospitalization costs (β: +$4,810, 95% confidence interval 3,280-6,350), length of stay (β: + 1.09 days, 95% confidence interval 0.70-1.48), and nonhome discharge (adjusted odds ratio: 1.15, 95% confidence interval 1.06-1.26).

Conclusion

Significant racial disparities exist in the management of and outcomes of lower extremity acute limb ischemia despite correction for variations in hospital amputation practices and other relevant hospital and patient characteristics. Whether the etiology lies primarily in patient, institution, or healthcare provider-specific factors has not yet been determined. Further studies of race-based disparities in management and outcomes of acute limb ischemia are warranted to provide effective and equitable care to all.

Background

This study investigated national implementation patterns and perioperative outcomes of minimally invasive gastrectomy (MIG) in gastric cancer surgery in the United States.

Methods

The National Inpatient Sample (NIS) was queried for patients who underwent elective gastrectomy for gastric cancer from 2008-2018. The MIG versus open gastrectomy approach was correlated with hospital factors, patient characteristics, and complications.

Results

There was more than a fivefold increase in MIG from 5.8% in 2008 to 32.9% in 2018 (nptrend < 0.001). Patients undergoing MIG had a lower Elixhauser Comorbidity Index (p = 0.001). On risk adjusted analysis, black patients (AOR = 0.77, p = 0.024) and patients with income below 25^th percentile (AOR = 0.80, p = 0.018) were less likely to undergo MIG. When these analyses were limited to minimally invasive capable centers only, these differences were not observed. Hospitals in the upper tertile of gastrectomy case volume, Northeast, and urban teaching centers were more likely to perform MIG. Overall, MIG was associated with a 0.7-day decrease in length of stay, reduced risk adjusted mortality rates (AOR = 0.58, p = 0.05), and a $4,700 increase in total cost.

Conclusions

In this national retrospective study, we observe socioeconomic differences in patients undergoing MIG, which is explained by hospital level factors in MIG utilization. We demonstrate that MIG is associated with a lower mortality compared with open gastrectomy. Establishing MIG as a safe approach to gastric cancers and understanding regional differences in implementation patterns can inform delivery of equitable high-quality health care.

Laryngeal complications (LCs) following cardiac operations contribute to increased morbidity and resource utilization. Using a nationally representative cohort of cardiac surgical patients, we characterized the incidence of LC as well as its associated clinical and financial outcomes. All adults undergoing coronary artery bypass grafting and/or valvular operations were identified using the 2010-2017 Nationwide Readmissions Database. International Classification of Diseases 9th and 10th Revision diagnosis codes were used to identify LC. Trends were analyzed using a rank-based, non-parametric test (nptrend). Multivariable linear and logistic regressions were used to evaluate risk factors for LC, and its impact on mortality, complications, resource use and 30-day non-elective readmissions. Of an estimated 2,319,628 patients, 1.7% were diagnosed with perioperative LC, with rising incidence from 1.5% in 2010 to 1.8% in 2017 (nptrend < 0.001). After adjustment, female sex [adjusted odds ratio 1.08, 95% confidence interval (CI) 1.04-1.12], advancing age, and multi-valve procedures (1.51, 95% CI 1.36-1.67, reference: isolated CABG) were associated with increased odds of LC. Despite no risk-adjusted effect on mortality, LC was associated with increased odds of pneumonia (2.88, 95% CI 2.72-3.04), tracheostomy (4.84, 95% CI 4.44-5.26), and readmission (1.32, 95% CI 1.26-1.39). In addition, LC was associated with a 7.7-day increment (95% CI 7.4-8.0) in hospitalization duration and $24,200 (95% CI 23,000-25,400) in attributable costs. The present study found LC to be associated with increased perioperative sequelae and resource utilization. The development and application of active screening protocols for post-surgical LC are warranted to increase early detection and reduce associated morbidity.