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Chaudhary MA, Schoenfeld AJ, Harlow AF, Ranjit A, Scully R, Chowdhury R, Sharma M, Nitzschke S, Koehlmoos T, Haider AH. Incidence and Predictors of Opioid Prescription at Discharge After Traumatic Injury. JAMA Surg 2017. [PMID: 28636707 DOI: 10.1001/jamasurg.2017.1685] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance In the current health care environment with increased scrutiny and growing concern regarding opioid use and abuse, there has been a push toward greater regulation over prescriptions of opioids. Trauma patients represent a population that may be affected by this regulation, as the incidence of pain at hospital discharge is greater than 95%, and opioids are considered the first line of treatment for pain management. However, the use of opioid prescriptions in trauma patients at hospital discharge has not been explored. Objective To study the incidence and predictors of opioid prescription in trauma patients at discharge in a large national cohort. Design, Setting, and Participants Analysis of adult (18-64 years), opioid-naive trauma patients who were beneficiaries of Military Health Insurance (military personnel and their dependents) treated at both military health care facilities and civilian trauma centers and hospitals between January 1, 2006, and December 31, 2013, was conducted. Patients with burns, foreign body injury, toxic effects, or late complications of trauma were excluded. Prior diagnosis of trauma within 1 year and in-hospital death were also grounds for exclusion. Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors were considered covariates. The Drug Enforcement Administration's list of scheduled narcotics was used to query opioid use. Unadjusted and adjusted logistic regression models were used to determine the predictors of opioid prescription. Data analysis was performed from June 7 to August 21, 2016. Exposures Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors. Main Outcomes and Measures Prescription of opioid analgesics at discharge. Results Among the 33 762 patients included in the study (26 997 [80.0%] men; mean [SD] age, 32.9 [13.3] years), 18 338 (54.3%) received an opioid prescription at discharge. In risk-adjusted models, older age (45-64 vs 18-24 years: odds ratio [OR], 1.28; 95% CI, 1.13-1.44), marriage (OR, 1.26; 95% CI, 1.20-1.34), and higher Injury Severity Score (≥9 vs <9: OR, 1.40; 95% CI, 1.32-1.48) were associated with a higher likelihood of opioid prescription at discharge. Male sex (OR, 0.76; 95% CI, 0.69-0.83) and anxiety (OR, 0.82; 95% CI, 0.73-0.93) were associated with a decreased likelihood of opioid prescription at discharge. Conclusions and Relevance The incidence of opioid prescription at discharge (54.3%) closely matches the incidence of moderate to severe pain in trauma patients, indicating appropriate prescribing practices. We advocate that injury severity and level of pain-not arbitrary regulations-should inform the decision to prescribe opioids.
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Castillo-Angeles M, Smink DS, Changala M, Kwakye G, Doherty GM, Haider AH, Rangel E. Pregnancy and Motherhood During Surgical Training: A Qualitative Assessment. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Chaudhary MA, Shah AA, Zogg CK, Changoor N, Chao G, Nitzschke S, Havens JM, Haider AH. Differences in rural and urban outcomes: a national inspection of emergency general surgery patients. J Surg Res 2017; 218:277-284. [DOI: 10.1016/j.jss.2017.06.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/20/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022]
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Scott JW, Havens JM, Raykar N, Rose JA, Salim A, Haider AH, Meara JG, Shrime MG. High Risk of Catastrophic Health Expenditure among Uninsured Emergency Surgery Patients in the United States. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Chaudhary MA, Sharma M, Sturgeon DJ, Scully R, Koehlmoos T, Haider AH, Schoenfeld AJ. Racial Disparities in Long-Term Outcomes for Trauma Absent In a Racially Diverse, Universally Insured Population. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Herrera-Escobar JP, Apoj M, Al Rafai SS, Harlow A, Brasel KJ, Kasotakis G, Kaafarani HM, Velmahos GC, Salim A, Haider AH. Routine Collection of Long-Term Patient-Centered Outcomes after Trauma: A Multi-Institutional Experience. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.1033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Sharma M, Nitzschke SL, Chaudhary MA, Sturgeon DJ, Goralnick E, Salim A, Koehlmoos T, Haider AH, Schoenfeld AJ. Surgical Outpatient Care Reduces Avoidable Emergency Department Visits among Trauma Patients. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Burns CJ, Nitzschke SL, Chung KK, Cancio LC, Olufajo OA, Jiang W, Haider AH, Salim A. Do Burn Patients Have a Lower Incidence of Venous Thromboembolism than Non-Burn Trauma Patients? J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.1007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chowdhury R, Chaudhary MA, Sturgeon DJ, Jiang W, Yau AL, Koehlmoos TP, Haider AH, Schoenfeld AJ. The impact of hepatitis C virus infection on 90-day outcomes following major orthopaedic surgery: a propensity-matched analysis. Arch Orthop Trauma Surg 2017; 137:1181-1186. [PMID: 28674736 DOI: 10.1007/s00402-017-2742-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The impact of hepatitis C virus (HCV) infection on outcomes following major orthopaedic interventions, such as joint arthroplasty or spine surgery, has not been effectively studied in the past. Most prior studies are impaired by small samples, limited surveillance for adverse events, or the potential for selection bias to confound results. In this context, we sought to evaluate the impact of HCV infection on 90-day outcomes following joint arthroplasty or spine surgery using propensity-matched techniques. MATERIALS AND METHODS This study utilized 2006-2014 claims from TRICARE insurance. Adults who received spine surgical procedures, total knee and hip arthroplasty were identified. Covariates included demographic factors, a diagnosis of HCV and medical co-morbidities defined by International Classification of Disease-9th revision (ICD-9) code. Outcomes consisted of 30- and 90-day mortality, complications and readmission. A propensity score was used to balance the cohorts with logistic regression techniques employed to determine the influence of HCV infection on post-operative outcomes. RESULTS The propensity-matched cohort consisted of 2262 patients (1131 with and without HCV). Following logistic regression, patients with HCV were found to have increased odds of 30-day complications (OR 1.87; 95% CI 1.33, 2.64; p < 0.001), 90-day complications (OR 1.55; 95% CI 1.16, 2.08; p = 0.003) and 30-day readmission (OR 1.46; 95% CI 1.04, 2.05; p = 0.03). CONCLUSION HCV infection was found to increase the risk of complication and readmission following spine surgery and total joint arthroplasty. Patients should be counseled on their increased risk prior to surgery. Health systems that treat a higher percentage of patients with HCV need to consider the increased risk of complications and readmission when negotiating with insurance carriers.
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Schoenfeld AJ, Nwosu K, Jiang W, Yau AL, Chaudhary MA, Scully RE, Koehlmoos T, Kang JD, Haider AH. Risk Factors for Prolonged Opioid Use Following Spine Surgery, and the Association with Surgical Intensity, Among Opioid-Naive Patients. J Bone Joint Surg Am 2017; 99:1247-1252. [PMID: 28763410 DOI: 10.2106/jbjs.16.01075] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is a growing concern that the use of prescription opioids following surgical interventions, including spine surgery, may predispose patients to chronic opioid use and abuse. We sought to estimate the proportion of patients using opioids up to 1 year after discharge following common spinal surgical procedures and to identify factors associated with sustained opioid use. METHODS This study utilized 2006 to 2014 data from TRICARE insurance claims obtained from the Military Health System Data Repository. Adults who underwent 1 of 4 common spinal surgical procedures (discectomy, decompression, lumbar posterolateral arthrodesis, or lumbar interbody arthrodesis) were identified. Patients with a history of opioid use in the 6 months preceding surgery were excluded. Posterolateral arthrodesis and interbody arthrodesis were considered procedures of high intensity, and discectomy and decompression, low intensity. Covariates included demographic factors, preoperative diagnoses, comorbidities, postoperative complications, and mental health disorders. Risk-adjusted Cox proportional hazard models were used to evaluate the time to opioid discontinuation. RESULTS This study included 9,991 patients. Eighty-four percent filled at least 1 opioid prescription on discharge. At 30 days following discharge, 8% continued opioid use; at 3 months, 1% continued use; and at 6 months, 0.1%. In the adjusted analysis, the low-intensity surgical procedures were associated with a higher likelihood of discontinuing opioid use (discectomy: hazard ratio [HR] = 1.43, 95% confidence interval [CI] = 1.36 to 1.50; and decompression: HR = 1.34, 95% CI = 1.25 to 1.43). Depression (HR = 0.84, 95% CI = 0.77 to 0.90) was significantly associated with a decreased likelihood of discontinuing opioid use (p < 0.001). CONCLUSIONS By 6 months following discharge, nearly all patients had discontinued opioid use after spine surgery. As only 0.1% of the patients continued opioid use at 6 months following surgery, these results indicate that spine surgery among opioid-naive patients is not a major driver of long-term prescription opioid use. Socioeconomic status and pre-existing mental health disorders may be factors associated with sustained opioid use following spine surgery. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Wolf LL, Chowdhury R, Tweed J, Vinson L, Losina E, Haider AH, Qureshi FG. Factors Associated with Pediatric Mortality from Motor Vehicle Crashes in the United States: A State-Based Analysis. J Pediatr 2017; 187:295-302.e3. [PMID: 28552450 PMCID: PMC5558848 DOI: 10.1016/j.jpeds.2017.04.044] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 03/03/2017] [Accepted: 04/20/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To examine geographic variation in motor vehicle crash (MVC)-related pediatric mortality and identify state-level predictors of mortality. STUDY DESIGN Using the 2010-2014 Fatality Analysis Reporting System, we identified passengers <15 years of age involved in fatal MVCs, defined as crashes on US public roads with ≥1 death (adult or pediatric) within 30 days. We assessed passenger, driver, vehicle, crash, and state policy characteristics as factors potentially associated with MVC-related pediatric mortality. Our outcomes were age-adjusted, MVC-related mortality rate per 100 000 children and percentage of children who died of those in fatal MVCs. Unit of analysis was US state. We used multivariable linear regression to define state characteristics associated with higher levels of each outcome. RESULTS Of 18 116 children in fatal MVCs, 15.9% died. The age-adjusted, MVC-related mortality rate per 100 000 children varied from 0.25 in Massachusetts to 3.23 in Mississippi (mean national rate of 0.94). Predictors of greater age-adjusted, MVC-related mortality rate per 100 000 children included greater percentage of children who were unrestrained or inappropriately restrained (P < .001) and greater percentage of crashes on rural roads (P = .016). Additionally, greater percentages of children died in states without red light camera legislation (P < .001). For 10% absolute improvement in appropriate child restraint use nationally, our risk-adjusted model predicted >1100 pediatric deaths averted over 5 years. CONCLUSIONS MVC-related pediatric mortality varied by state and was associated with restraint nonuse or misuse, rural roads, vehicle type, and red light camera policy. Revising state regulations and improving enforcement around these factors may prevent substantial pediatric mortality.
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Schoenfeld AJ, Jiang W, Harris MB, Cooper Z, Koehlmoos T, Learn PA, Weissman JS, Haider AH. Association Between Race and Postoperative Outcomes in a Universally Insured Population Versus Patients in the State of California. Ann Surg 2017; 266:267-273. [DOI: 10.1097/sla.0000000000001958] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Shields R, Lau B, Haider AH. Emergency General Surgery Needs for Lesbian, Gay, Bisexual, and Transgender Patients. JAMA Surg 2017; 152:617-618. [DOI: 10.1001/jamasurg.2017.0541] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Ranjit A, Sharma M, Romano A, Jiang W, Staat B, Koehlmoos T, Haider AH, Little SE, Witkop CT, Robinson JN, Cohen SL. Does Universal Insurance Mitigate Racial Differences in Minimally Invasive Hysterectomy? J Minim Invasive Gynecol 2017; 24:790-796. [DOI: 10.1016/j.jmig.2017.03.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
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Chaudhary MA, Scully R, Jiang W, Chowdhury R, Zogg CK, Sharma M, Ranjit A, Koehlmoos T, Haider AH, Schoenfeld AJ. Patterns of use and factors associated with early discontinuation of opioids following major trauma. Am J Surg 2017; 214:792-797. [PMID: 28619266 DOI: 10.1016/j.amjsurg.2017.05.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 05/12/2017] [Accepted: 05/29/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Inappropriate use of prescription opioids is a growing public-health issue. We sought to estimate the proportion of traumatic injury patients using legal prescription opioids up to 1-year after hospitalization. METHODS We used 2006-2014 claims data from TRICARE insurance to identify adults hospitalized secondary to trauma between 2007 and 2013. Prescription opioid use was evaluated for one-year post-discharge. Risk-adjusted Cox Proportional-hazards models were used to evaluate predictors of opioid discontinuation. RESULTS Only 1% of patients sustained legal prescription opioid use at 1-year following trauma. Lower socioeconomic status (HR 0.92, 95% CI 0.87-0.98) and higher injury severity (HR 0.88, 95% CI 0.84-0.91) were associated with sustained use. Younger patients (HR 1.12, 95% CI 1.04-1.21) and Black patients (HR 1.09, 95% CI 1.04-1.15) were found to have a higher likelihood of opioid discontinuation. CONCLUSIONS In this population, adult patients who sustained trauma were not at high risk of sustained legal prescription opioid use.
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Haider AH, Schneider EB, Kodadek LM, Adler RR, Ranjit A, Torain M, Shields RY, Snyder C, Schuur JD, Vail L, German D, Peterson S, Lau BD. Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity : The EQUALITY Study. JAMA Intern Med 2017; 177:819-828. [PMID: 28437523 PMCID: PMC5818827 DOI: 10.1001/jamainternmed.2017.0906] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 02/27/2017] [Indexed: 01/01/2023]
Abstract
Importance The Institute of Medicine and The Joint Commission recommend routine documentation of patients' sexual orientation in health care settings. Currently, very few health care systems collect these data since patient preferences and health care professionals' support regarding collection of data about patient sexual orientation are unknown. Objective To identify the optimal patient-centered approach to collect sexual orientation data in the emergency department (ED) in the Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity study. Design, Setting, and Participants An exploratory, sequential, mixed-methods design was used first to evaluate qualitative interviews conducted in the Baltimore, Maryland, and Washington, DC, areas. Fifty-three patients and 26 health care professionals participated in the qualitative interviews. Interviews were followed by a national online survey, in which 1516 (potential) patients (244 lesbian, 289 gay, 179 bisexual, and 804 straight) and 429 ED health care professionals (209 physicians and 220 nurses) participated. Survey participants were recruited using random digit dialing and address-based sampling techniques. Main Outcomes and Measures Qualitative interviews were used to obtain the perspectives of patients and health care professionals on sexual orientation data collection, and a quantitative survey was used to gauge patients' and health care professionals' willingness to provide or obtain sexual orientation information. Results Mean (SD) age of patient and clinician participants was 49 (16.4) and 51 (9.4) years, respectively. Qualitative interviews suggested that patients were less likely to refuse to provide sexual orientation than providers expected. Nationally, 154 patients (10.3%) reported that they would refuse to provide sexual orientation; however, 333 (77.8%) of all clinicians thought patients would refuse to provide sexual orientation. After adjustment for demographic characteristics, only bisexual patients had increased odds of refusing to provide sexual orientation compared with heterosexual patients (odds ratio, 2.40; 95% CI, 1.26-4.56). Conclusions and Relevance Patients and health care professionals have discordant views on routine collection of data on sexual orientation. A minority of patients would refuse to provide sexual orientation. Implementation of a standardized, patient-centered approach for routine collection of sexual orientation data is required on a national scale to help to identify and address health disparities among lesbian, gay, and bisexual populations.
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Maragh-Bass AC, Torain M, Adler R, Ranjit A, Schneider E, Shields RY, Kodadek LM, Snyder CF, German D, Peterson S, Schuur J, Lau BD, Haider AH. Is It Okay To Ask: Transgender Patient Perspectives on Sexual Orientation and Gender Identity Collection in Healthcare. Acad Emerg Med 2017; 24:655-667. [PMID: 28235242 DOI: 10.1111/acem.13182] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 02/14/2017] [Accepted: 02/21/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The National Academy of Medicine and Joint Commission recommend routine documentation of sexual orientation (SO) and gender identity (GI) in healthcare to address lesbian, gay, bisexual, or transgender (LGBT) health disparities. We explored transgender patient-reported views on the importance on SO/GI collection, their willingness to disclose, and their perceived facilitators of SO/GI collection in primary care and emergency department (ED) settings. METHODS We recruited a national sample of self-identified transgender patients. Participants completed demographic questions, survey questions, and free-response comments regarding their views on SO/GI collection. Data were analyzed using descriptive statistics; inductive content analysis was conducted with open-ended responses. RESULTS Patients mostly self-identified as male gender (54.5%), white (58.4%), and SO other than heterosexual or LGB (33.7%; N = 101). Patients felt that it was more important for primary care providers to know their GI than SO (89.1% vs. 57%; p < 0.001); there was no difference among reported importance for ED providers to know the patients' SO versus GI. Females were more likely than males to report medical relevance to chief complaint as a facilitator to SO disclosure (89.1% vs. 80%; p = 0.02) and less likely to identify routine collection from all patients as a facilitator to GI disclosure (67.4% vs. 78.2%; p = 0.09). Qualitatively, many patients reported that medical relevance to chief complaint and an LGBT-friendly environment would increase willingness to disclose their SO/GI. Patients also reported need for educating providers in LGBT health prior to implementing routine SO/GI collection. CONCLUSIONS Patients see the importance of providing GI more than SO to providers; nonetheless they are willing to disclose SO/GI in general.. Findings also suggest that gender differences may exist in facilitators of SO/GI disclosure. Given the underrepresentation of transgender patients in healthcare, it is crucial for providers to address their concerns with SO/GI disclosure, which include LGBT education for medical staff and provision of a safe environment.
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Scott JW, Neiman PU, Najjar PA, Tsai TC, Scott KW, Shrime MG, Cutler DM, Salim A, Haider AH. Potential impact of Affordable Care Act-related insurance expansion on trauma care reimbursement. J Trauma Acute Care Surg 2017; 82:887-895. [PMID: 28431415 PMCID: PMC5468098 DOI: 10.1097/ta.0000000000001400] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nearly one quarter of trauma patients are uninsured and hospitals recoup less than 20% of inpatient costs for their care. This study examines changes to hospital reimbursement for inpatient trauma care if the full coverage expansion provisions of the Affordable Care Act (ACA) were in effect. METHODS We abstracted nonelderly adults (ages 18-64 years) admitted for trauma from the Nationwide Inpatient Sample during 2010-the last year before most major ACA coverage expansion policies. We calculated national and facility-level reimbursements and trauma-related contribution margins using Nationwide Inpatient Sample-supplied cost-to-charge ratios and published reimbursement rates for each payer type. Using US census data, we developed a probabilistic microsimulation model to determine the proportion of pre-ACA uninsured trauma patients that would be expected to gain private insurance, Medicaid, or remain uninsured after full implementation of the ACA. We then estimated the impact of these coverage changes on national and facility-level trauma reimbursement for this population. RESULTS There were 145,849 patients (representing 737,852 patients nationwide) included. National inpatient trauma costs for patients aged 18 years to 64 years totaled US $14.8 billion (95% confidence interval [CI], 12.5,17.1). Preexpansion reimbursements totaled US $13.7 billion (95% CI, 10.8-14.7), yielding a national margin of -7.9% (95% CI, -10.6 to -5.1). Postexpansion projected reimbursements totaled US $15.0 billion (95% CI, 12.7-17.3), increasing the margin by 9.3 absolute percentage points to +1.4% (95% CI, -0.3 to +3.2). Of the 263 eligible facilities, 90 (34.2%) had a positive trauma-related contribution margin in 2010, which increased to 171 (65.0%) using postexpansion projections. Those facilities with the highest proportion of uninsured and racial/ethnic minorities experienced the greatest gains. CONCLUSION Health insurance coverage expansion for uninsured trauma patients has the potential to increase national reimbursement for inpatient trauma care by over one billion dollars and nearly double the proportion of hospitals with a positive margin for trauma care. These data suggest that insurance coverage expansion has the potential to improve trauma centers' financial viability and their ability to provide care for their communities. LEVEL OF EVIDENCE Economic analysis, level II.
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Ranjit A, Chaudhary MA, Jiang W, Zhan T, Schneider EB, Cohen SL, Little SE, Haider AH, Robinson JN, Witkop CT. Disparities in receipt of a laparoscopic operation for ectopic pregnancy among TRICARE beneficiaries. Surgery 2017; 161:1341-1347. [DOI: 10.1016/j.surg.2016.09.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/08/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022]
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146
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Maragh-Bass AC, Torain M, Adler R, Schneider E, Ranjit A, Kodadek LM, Shields R, German D, Snyder C, Peterson S, Schuur J, Lau B, Haider AH. Risks, Benefits, and Importance of Collecting Sexual Orientation and Gender Identity Data in Healthcare Settings: A Multi-Method Analysis of Patient and Provider Perspectives. LGBT Health 2017; 4:141-152. [DOI: 10.1089/lgbt.2016.0107] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Maragh-Bass AC, Torain M, Adler R, Schneider E, Ranjit A, Kodadek LM, Shields R, German D, Snyder C, Peterson S, Schuur J, Lau B, Haider AH. Risks, Benefits, and Importance of Collecting Sexual Orientation and Gender Identity Data in Healthcare Settings: A Multi-Method Analysis of Patient and Provider Perspectives. LGBT Health 2017. [PMID: 28221820 DOI: 10.1089/lgbt.2016.0107:10.1089/lgbt.2016.0107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
Abstract
PURPOSE Research suggests that LGBT populations experience barriers to healthcare. Organizations such as the Institute of Medicine recommend routine documentation of sexual orientation (SO) and gender identity (GI) in healthcare, to reduce LGBT disparities. We explore patient views regarding the importance of SO/GI collection, and patient and provider views on risks and benefits of routine SO/GI collection in various settings. METHODS We surveyed LGBT/non-LGBT patients and providers on their views on SO/GI collection. Weighted data were analyzed with descriptive statistics; content analysis was conducted with open-ended responses. RESULTS One-half of the 1516 patients and 60% of 429 providers were female; 64% of patients and 71% of providers were White. Eighty percent of providers felt that collecting SO data would offend patients, whereas only 11% of patients reported that they would be offended. Patients rated it as more important for primary care providers to know the SO of all patients compared with emergency department (ED) providers knowing the SO of all patients (41.3% vs. 31.6%; P < 0.001). Patients commonly perceived individualized care as an SO/GI disclosure benefit, whereas providers perceived patient-provider interaction improvement as the main benefit. Patient comments cited bias/discrimination risk most frequently (49.7%; N = 781), whereas provider comments cited patient discomfort/offense most frequently (54.5%; N = 433). CONCLUSION Patients see the importance of SO/GI more in primary care than ED settings. However, many LGBT patients seek ED care due to factors including uninsurance; therefore, the ED may represent an initial point of contact for SO/GI collection. Therefore, patient-centered approaches to collecting SO/GI are needed. Patients and providers differed in perceived risks and benefits to routine SO/GI collection. Provider training in LGBT health may address patients' bias/discrimination concerns, and ultimately reduce LGBT health disparities.
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Zogg CK, Payró Chew F, Scott JW, Wolf LL, Tsai TC, Najjar P, Olufajo OA, Schneider EB, Haut ER, Haider AH, Canner JK. Implications of the Patient Protection and Affordable Care Act on Insurance Coverage and Rehabilitation Use Among Young Adult Trauma Patients. JAMA Surg 2016; 151:e163609. [PMID: 27760245 DOI: 10.1001/jamasurg.2016.3609] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Trauma is the leading cause of death and disability among young adults, who are also among the most likely to be uninsured. Efforts to increase insurance coverage, including passage of the Patient Protection and Affordable Care Act (ACA), were intended to improve access to care and promote improvements in outcomes. However, despite reported gains in coverage, the ACA's success in promoting use of high-quality care and enacting changes in clinical end points remains unclear. Objectives To assess for observed changes in insurance coverage and rehabilitation use among young adult trauma patients associated with the ACA, including the Dependent Coverage Provision (DCP) and Medicaid expansion/open enrollment, and to consider possible insurance and rehabilitation differences between DCP-eligible vs -ineligible patients and among stratified demographic and community subgroups. Design, Setting, and Participants A longitudinal assessment of DCP implementation and Medicaid expansion/open enrollment using risk-adjusted before-and-after, difference-in-difference, and interrupted time-series analyses was conducted. Eleven years (January 1, 2005, to September 31, 2015) of Maryland Health Services Cost Review Commission data, representing complete patient records from all payers within the state, were used to identify all hospitalized young adult (aged 18-34 years) trauma patients in Maryland during the study period. Results Of the 69 507 hospitalized patients included, 50 548 (72.7%) were male, and the mean (SD) age was 25 (5) years. Before implementation of the DCP, 1 of 4 patients was uninsured. After ACA implementation, the number fell to less than 1 of 10, with similar patterns emerging in emergency department and outpatient settings. The change was primarily driven by Medicaid expansion/open enrollment, which corresponded to a 20.1 percentage-point increase in Medicaid (95% CI, 18.9-21.3) and an 18.2 percentage-point decrease in uninsured (95% CI, -19.3 to -17.2). No changes were detected among privately insured patients. Rehabilitation use increased by 5.4 percentage points (95% CI, 4.5-6.2)-a 60% relative increase from a baseline of 9%. Mortality (-0.5; 95% CI, -0.9 to -0.1) and failure-to-rescue rates (-4.5; 95% CI, -7.4 to -1.6) also significantly declined. Stratified changes point to significant differences in the percentage of uninsured patients and rehabilitation access across the board, mitigating or even eradicating disparities in certain cases. Conclusions and Relevance For patients who are injured, young, and uninsured, Medicaid expansion/open enrollment in Maryland changed insurance coverage and altered patient outcomes in ways that the DCP alone was never intended to do. Implementation of Medicaid expansion/open enrollment transformed the landscape of trauma coverage, directly affecting the health of one of the country's most vulnerable at-risk groups.
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Jarman MP, Castillo RC, Carlini AR, Kodadek LM, Haider AH. Rural risk: Geographic disparities in trauma mortality. Surgery 2016; 160:1551-1559. [PMID: 27506860 PMCID: PMC5118091 DOI: 10.1016/j.surg.2016.06.020] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 06/03/2016] [Accepted: 06/06/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Barriers to trauma care for rural populations are well documented, but little is known about the magnitude of urban-rural disparities in injury mortality. This study sought to quantify differences in injury mortality comparing rural and nonrural residents with traumatic injuries. METHODS Using data from the 2009-2010 Nationwide Emergency Department Sample, multiple logistic regression analyses were conducted to estimate odds of death after traumatic injury for rural residents compared with nonrural residents, while controlling for age, sex, injury type and severity, comorbidities, trauma designation, and Census region. RESULTS Rural residents were 14% more likely to die after traumatic injury compared with nonrural residents (P < .001). Increased odds of death for rural residents were observed at level I (odds ratio = 1.20, P < .001), level II (odds ratio = 1.34, P < .001), and level IV/nontrauma centers (odds ratio = 1.23, P < .001). The disparity was greatest for injuries occurring in the South and Midwest (odds ratio = 1.54, P < .001 and odds ratio = 2.06, P < .001, respectively) and for cases with an injury severity score <9 or unknown severity (odds ratio = 2.09, P < .001 and odds ratio = 1.31, P < .001, respectively). CONCLUSION Rural residents are significantly more likely than nonrural residents to die after traumatic injury. This disparity varies by trauma center designation, injury severity, and US Census region. Distance and time to treatment likely play a role in rural injury outcomes, along with regional differences in prehospital care and trauma system organization.
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Long Roche K, Angarita AM, Cristello A, Lippitt M, Haider AH, Bowie JV, Fader AN, Tergas AI. "Little Big Things": A Qualitative Study of Ovarian Cancer Survivors and Their Experiences With the Health Care System. J Oncol Pract 2016; 12:e974-e980. [PMID: 27601509 DOI: 10.1200/jop.2015.007492] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Navigation of a complex and ever-changing health care system can be stressful and detrimental to psychosocial well-being for patients with serious illness. This study explored women's experiences with navigating the health care system during treatment for ovarian cancer. METHODS Focus groups moderated by trained investigators were conducted with ovarian cancer survivors at an academic cancer center. Personal experiences with cancer treatment, provider relationships, barriers to care, and the health care system were explored. Sessions were audiotaped, transcribed, and coded by using grounded theory. Subsequently, one-on-one interviews were conducted to further evaluate common themes. RESULTS Sixteen ovarian cancer survivors with a median age of 59 years participated in the focus group study. Provider consistency, personal touch, and patient advocacy positively affected the care experience. Treatment with a known provider who was well acquainted with the individual's medical history was deemed an invaluable aspect of care. Negative experiences that burdened patients, referred to as the "little big things," included systems-based challenges, which were scheduling, wait times, pharmacy, transportation, parking, financial, insurance, and discharge. Consistency, a care team approach, effective communication, and efficient connection to resources were suggested as ways to improve patients' experiences. CONCLUSION Systems-based challenges were perceived as burdens to ovarian cancer survivors at our institution. The role of a consistent, accessible care team and efficient delivery of resources in the care of women with ovarian cancer should be explored further.
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