title: Hospital-acquired conditions after bariatric surgery: we can predict, but can we prevent?
abstract: BACKGROUND
  Centers for Medicare and Medicaid Services initiated a non-payment policy for certain hospital-acquired conditions (HACs) in 2008. This study aimed to determine the rate of the three most common HACs (surgical site infection (SSI), urinary tract infection (UTI), and venous thromboembolism (VTE)) among bariatric surgery patients. Additionally, the association of HACs with patient factors and the effect of HACs on post-operative outcomes were investigated.
  
  
  METHODS
  Patients over 18 years with a body mass index (BMI) ≥ 35 who underwent bariatric surgery were identified using the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012). Patients were grouped into two categories: HAC versus no HAC patients and baseline characteristics and outcomes, including 30-day mortality, reoperation, and mean length of stay (LOS) were compared. Multivariable logistic regression analysis was performed to identify the risk factors for developing a HAC.
  
  
  RESULTS
  98,553 patients were identified, 2,809 (2.9%) developed at least one HACs. SSI was the most common HAC (1.8%), followed by UTI (0.7%) and VTE (0.4%). The rate of these HACs significantly decreased from 4.6% in 2005-2006 to 2.5% in 2012 (p < 0.001). Laparoscopic gastric banding was associated with the lowest rates of HAC (1.3%) and open gastric bypass with the highest (8.0%). HAC patients had significantly higher rates of in-hospital mortality (0.8 vs. 0.1%, p < 0.001) and LOS (3.9 vs. 2.1 days, p < 0.001). On adjusted analysis, open GBP patients had 5.36-fold higher odds of developing a HAC. Interestingly, the presence of a resident surgeon 7-11 years post graduation was associated with significantly increased odds of HACs (1.86, 1.50-2.31, p < 0.001).
  
  
  CONCLUSIONS
  Our data demonstrate a strong correlation between these three HACs following bariatric surgery and factors intrinsic to the bariatric patient population. This calls into question the non-payment policy for inherent patient factors on which they cannot have impact. These findings are important to help inform health care policy decisions regarding access to care for bariatric surgery patients.
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA, alidor1@jhmi.edu.
authors.forename: Anne O
authors.initials: AO
authors.lastname: Lidor
authors.forename: Erin
authors.initials: E
authors.lastname: Moran-Atkin
authors.forename: Miloslawa
authors.initials: M
authors.lastname: Stem
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Magnuson
authors.forename: Kimberley E
authors.initials: KE
authors.lastname: Steele
authors.forename: Richard
authors.initials: R
authors.lastname: Feinberg
authors.forename: Michael A
authors.initials: MA
authors.lastname: Schweitzer
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D050110:Bariatric Surgery / Q000379:methods; D015992:Body Mass Index; D003428:Cross Infection / Q000209:etiology / Q000517:prevention & control*; D016208:Databases, Factual; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control*; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013530:Surgical Wound Infection / Q000209:etiology / Q000517:prevention & control*; D014481:United States; D014552:Urinary Tract Infections / Q000209:etiology / Q000517:prevention & control*; D054556:Venous Thromboembolism / Q000209:etiology / Q000517:prevention & control*