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Non-Robotic versus Robotic Cardiac Surgery: An Investigation of Critical Outcomes
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS difference of MACE between surgery cases and non-surgery controls and changes in risk over time following stent placement. Results: The cohort consisted of 22,501 surgery and 45,002 non-surgery patients with a median age of 64. The majority of patients were white (94%) with DES (53%) and 37% had a history of MI within 6 months prior to stent. Most surgeries were integumentary (17%) with a median RVU of 6.6 (IQR 2.2-11.7) and 65% outpatient. The MACE rate in the surgery cohort was 4.5% as compared to 1.3% in the controls. In both cohorts, the MACE rate was higher in the 6 months following stent and decreased over time (Figure). The overall difference in MACE between cases and controls across the 24 months following stent placement was 3.2% (2.9%-3.5%) with cases being more likely to experience a MACE in the postoperative period as compared to their matched controls [(RR¼3.4(3.1-3.7)]. After adjusting for surgical characteristics, the risk difference between cases and controls decreases across time and there is no incremental cardiac risk for surgery more than 6 months after stent. Examining specific postoperative outcomes, surgical cases were more likely to experience MI [RR¼4.2(3.1-5.6)] or death [RR¼1.7(1.1-2.5)] but not more likely to experience revascularization [RR¼1.2(0.9-2.5)]. Conclusions: In conclusion, adverse cardiac events following coronary stenting decrease over time for both surgical and non-surgical cohorts. Furthermore, the risk difference and the surgery adjusted risk difference decrease over time and reach baseline for surgical patients more than 6 months out from stent. These findings help inform clinical decision making regarding the incremental risk of surgery in cardiac stent patients.
39.3. Thirty-day Readmission and Mortality following Discharge to Skilled Nursing Facilities after Vascular Intervention. S. Fernandes-Taylor,1 T. L. Engelbert,1 J. Havlena,1 A. J. Kind,1 C. C. Greenberg,1 M. L. Schwarze,1 J. T. Wiseman,1 R. S. Saunders,1 M. A. Smith,1 K. Kent1; 1 University Of Wisconsin - Surgery, Madison, WI, USA Introduction: Readmission within 30 days of an acute hospital stay is frequent, costly, and increasingly subject to financial penalties by the Centers for Medicare and Medicaid Services (CMS). Early readmission after a vascular surgical procedure is most common among surgical procedures (24%). To reduce readmissions and coordinate care, vascular surgery patients are often discharged to skilled nursing facilities (SNF). Whether discharging vascular patients to SNF reduces readmission is unknown. To address this gap, we characterize 30day readmissions among vascular surgery patients discharged to SNFs to inform transitional care for these patients. Methods: We utilize the CMS Chronic Conditions Warehouse, a longitudinal 5% national random sample of Medicare beneficiaries, to describe 30-day readmission after discharge to SNF among patients treated with vascular intervention (carotid endarterectomy or stenting, abdominal aortic aneurysm (AAA) repair, or lower extremity revascularization from 2005-2009). Descriptive statistics and multivariable logistic regression were used to describe readmissions and subsequent mortality. Results: 3,578 patients were discharged to a SNF following carotid, AAA, or lower extremity procedures. 72% of SNF discharges were following lower extremity interventions, 66% were following open (not endovascular) surgery and 35% were following emergent operations. Surprisingly, 31% of patients experienced readmission within 30 days, most within the first week following discharge to SNFs. Of patients readmitted from SNFs, >25% had the readmitting diagnosis of wound infection or device complication. Respiratory and cardiac is-
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sues were also common reason for readmission (jointly 20% of readmissions). In multivariable analysis, readmission was associated with emergent first hospitalization (OR 1.3; p<.01), in-hospital venous thromboembolism (OR 1.3; p<.05), in-hospital urinary tract infection (OR 1.3; p<.05), comorbid COPD (OR 1.2; p<.05), or chronic renal failure (OR 1.2; p<.05). Interestingly, wound infection, hemorrhage, or device complications during the initial hospitalization were not associated with readmission from a SNF. Of patients readmitted from a SNF, 23.0% died within 60 days of the first hospital discharge, whereas the mortality was 8.1% for SNF patients who were not readmitted (p<.001). Conclusions: Our analysis demonstrates that almost a third of vascular patients discharged to a SNF are subsequently readmitted implying that many of these patients required care surpassing the capability of a SNF. Reasons for readmission include wound and graft complications, many of which develop post discharge. Medical complications are also a frequent cause of readmission from SNFs. Improved care coordination between hospital and SNF, the development of surgical specialty SNFs, and training of SNF staff in the management of surgical patients all have the potential to reduce readmission amongst vascular patients discharged to skilled nursing facilities.
39.4. Non-Robotic versus Robotic Cardiac Surgery: An Investigation of Critical Outcomes. F. Yanagawa,1 K. Bhuva,1 J. Martin,1 T. Bell,1 R. Grim,1 V. Ahuja1; 1York Hospital - Department Of Surgery, York, PA, USA Introduction: Robotic-assisted cardiac surgery is a minimally invasive approach to conventional open surgery, but its benefits and cost are still being studied. The purpose of this study was to compare outcomes, (complications, length of stay (LOS), total charges and mortality) between non-robotic and robotic-assisted cardiac surgery. Methods: Weighted HCUP-NIS (2008 and 2009) data of cardiac patients (ages 18+) who had operations including 1) valves/septa, 2) vessels, and 3) other heart and pericardium procedures were used for this study. Patients were grouped into non-robotic and robotic. Propensity score matching was used to match each robotic case to 2 non-robotic cases on 13 characteristics (age, gender, race, payer, Charlson score, hospital bed size, location, region and teaching status, income, and the 3 operation sub-types). Outcome variables were complications, median LOS, median in-hospital total charges (excluding acquisition and maintenance costs), and mortality. Results: There were a total of 706,174 cardiac cases comprising 703,498 non-robotic and 2,676 robotic cases. After propensity score matching there were 5,279 (66.4%) non-robotic cases and 2,676 (33.6%) robotic cases. Cardiac operations included 3,640 valves/septa, 4,201 vessels and 726 other heart and pericardium procedures. Comparative analysis revealed that robotic-assisted surgery had lower complications (28%), LOS (5 days), total charges ($97,409) and mortality (1.4%) than non-robotic complications (29.4%), LOS (6 days), total charges ($105,913) and mortality (1.7%). However, only LOS and total charges were statistically significant, p<.001. Conclusions: Overall, robotic surgery appears to have reduced mortality and complications; however, the findings were non-significant. Robotic surgery did have significantly reduced LOS and total charges compared to non-robotic surgery. Results of the present study support the contention that robotic surgery is as safe as non-robotic surgery and offers the surgeon an additional technique for performing cardiac surgery.
39.5. A Longitudinal Analysis of Mortality, Complications, and Failure to Rescue After Cardiac Surgery. A. A. Gonzalez,1,3 J. D. Dimick,3 J. D. Birkmeyer,3 A. A. Ghaferi3; 1University Of Illinois At Chicago Department Of Surgery, Chicago, IL, USA; 3University Of Michigan - Center For Healthcare Outcomes & Policy, Ann Arbor, MI, USA
39.3. Thirty-day Readmission and Mortality following Discharge to Skilled Nursing Facilities after Vascular Intervention. S. Fernandes-Taylor,1 T. L. Engelbert,1 J. Havlena,1 A. J. Kind,1 C. C. Greenberg,1 M. L. Schwarze,1 J. T. Wiseman,1 R. S. Saunders,1 M. A. Smith,1 K. Kent1; 1 University Of Wisconsin - Surgery, Madison, WI, USA Introduction: Readmission within 30 days of an acute hospital stay is frequent, costly, and increasingly subject to financial penalties by the Centers for Medicare and Medicaid Services (CMS). Early readmission after a vascular surgical procedure is most common among surgical procedures (24%). To reduce readmissions and coordinate care, vascular surgery patients are often discharged to skilled nursing facilities (SNF). Whether discharging vascular patients to SNF reduces readmission is unknown. To address this gap, we characterize 30day readmissions among vascular surgery patients discharged to SNFs to inform transitional care for these patients. Methods: We utilize the CMS Chronic Conditions Warehouse, a longitudinal 5% national random sample of Medicare beneficiaries, to describe 30-day readmission after discharge to SNF among patients treated with vascular intervention (carotid endarterectomy or stenting, abdominal aortic aneurysm (AAA) repair, or lower extremity revascularization from 2005-2009). Descriptive statistics and multivariable logistic regression were used to describe readmissions and subsequent mortality. Results: 3,578 patients were discharged to a SNF following carotid, AAA, or lower extremity procedures. 72% of SNF discharges were following lower extremity interventions, 66% were following open (not endovascular) surgery and 35% were following emergent operations. Surprisingly, 31% of patients experienced readmission within 30 days, most within the first week following discharge to SNFs. Of patients readmitted from SNFs, >25% had the readmitting diagnosis of wound infection or device complication. Respiratory and cardiac is-
613
sues were also common reason for readmission (jointly 20% of readmissions). In multivariable analysis, readmission was associated with emergent first hospitalization (OR 1.3; p<.01), in-hospital venous thromboembolism (OR 1.3; p<.05), in-hospital urinary tract infection (OR 1.3; p<.05), comorbid COPD (OR 1.2; p<.05), or chronic renal failure (OR 1.2; p<.05). Interestingly, wound infection, hemorrhage, or device complications during the initial hospitalization were not associated with readmission from a SNF. Of patients readmitted from a SNF, 23.0% died within 60 days of the first hospital discharge, whereas the mortality was 8.1% for SNF patients who were not readmitted (p<.001). Conclusions: Our analysis demonstrates that almost a third of vascular patients discharged to a SNF are subsequently readmitted implying that many of these patients required care surpassing the capability of a SNF. Reasons for readmission include wound and graft complications, many of which develop post discharge. Medical complications are also a frequent cause of readmission from SNFs. Improved care coordination between hospital and SNF, the development of surgical specialty SNFs, and training of SNF staff in the management of surgical patients all have the potential to reduce readmission amongst vascular patients discharged to skilled nursing facilities.
39.4. Non-Robotic versus Robotic Cardiac Surgery: An Investigation of Critical Outcomes. F. Yanagawa,1 K. Bhuva,1 J. Martin,1 T. Bell,1 R. Grim,1 V. Ahuja1; 1York Hospital - Department Of Surgery, York, PA, USA Introduction: Robotic-assisted cardiac surgery is a minimally invasive approach to conventional open surgery, but its benefits and cost are still being studied. The purpose of this study was to compare outcomes, (complications, length of stay (LOS), total charges and mortality) between non-robotic and robotic-assisted cardiac surgery. Methods: Weighted HCUP-NIS (2008 and 2009) data of cardiac patients (ages 18+) who had operations including 1) valves/septa, 2) vessels, and 3) other heart and pericardium procedures were used for this study. Patients were grouped into non-robotic and robotic. Propensity score matching was used to match each robotic case to 2 non-robotic cases on 13 characteristics (age, gender, race, payer, Charlson score, hospital bed size, location, region and teaching status, income, and the 3 operation sub-types). Outcome variables were complications, median LOS, median in-hospital total charges (excluding acquisition and maintenance costs), and mortality. Results: There were a total of 706,174 cardiac cases comprising 703,498 non-robotic and 2,676 robotic cases. After propensity score matching there were 5,279 (66.4%) non-robotic cases and 2,676 (33.6%) robotic cases. Cardiac operations included 3,640 valves/septa, 4,201 vessels and 726 other heart and pericardium procedures. Comparative analysis revealed that robotic-assisted surgery had lower complications (28%), LOS (5 days), total charges ($97,409) and mortality (1.4%) than non-robotic complications (29.4%), LOS (6 days), total charges ($105,913) and mortality (1.7%). However, only LOS and total charges were statistically significant, p<.001. Conclusions: Overall, robotic surgery appears to have reduced mortality and complications; however, the findings were non-significant. Robotic surgery did have significantly reduced LOS and total charges compared to non-robotic surgery. Results of the present study support the contention that robotic surgery is as safe as non-robotic surgery and offers the surgeon an additional technique for performing cardiac surgery.
39.5. A Longitudinal Analysis of Mortality, Complications, and Failure to Rescue After Cardiac Surgery. A. A. Gonzalez,1,3 J. D. Dimick,3 J. D. Birkmeyer,3 A. A. Ghaferi3; 1University Of Illinois At Chicago Department Of Surgery, Chicago, IL, USA; 3University Of Michigan - Center For Healthcare Outcomes & Policy, Ann Arbor, MI, USA