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Hoyer EH, Needham DM, Miller J, Deutschendorf A, Friedman M, Brotman DJ. Functional status impairment is associated with unplanned readmissions. Arch Phys Med Rehabil 2013; 94:1951-8. [PMID: 23810355 DOI: 10.1016/j.apmr.2013.05.028] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 04/24/2013] [Accepted: 05/26/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine whether functional status on admission to a Comprehensive Integrated Inpatient Rehabilitation Program (CIIRP) is associated with unplanned readmission to acute care. DESIGN Retrospective cohort study. SETTING Academic hospital-based CIIRP. PARTICIPANTS Consecutive patients (N=1515) admitted to a CIIRP between January 2009 and June 2012. INTERVENTIONS Patients' functional status, the primary exposure variable, was assessed using tertiles of the total FIM score at CIIRP admission, with secondary analyses using the FIM motor and cognitive domains. A propensity score, consisting of 25 relevant clinical and demographic variables, was used to adjust for confounding in the analysis. MAIN OUTCOME MEASURES Readmission to acute care was categorized as (1) readmission before planned discharge from the CIIRP, (2) readmission within 30 days of discharge from the CIIRP, and (3) total readmissions from both groups, with total readmissions being the a priori primary outcome. RESULTS Among the 1515 patients, there were 347 total readmissions. Total readmissions were significantly associated with FIM scores, with adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for the lowest and middle FIM tertiles versus the highest tertile (AOR=2.6; 95% CI, 1.9-3.7; P<.001 and AOR=1.7; 95% CI, 1.2-2.4; P=.002, respectively). There were similar findings for secondary analyses of readmission before planned discharge from the CIIRP (AOR=3.5; 95% CI, 2.2-5.8; P<.001 and AOR=2.1; 95% CI, 1.3-3.5l P=.002, respectively), and a weaker association for readmissions after discharge from the CIIRP (AOR=1.6; 95% CI, 1.0-2.4; P=.047 and AOR=1.3; 95% CI, 0.8-1.9; P=.28, respectively). The FIM motor domain score was more strongly associated with readmissions than the FIM cognitive score. CONCLUSIONS Functional status on admission to the CIIRP is strongly associated with readmission to acute care, particularly for motor aspects of functional status and readmission before planned discharge from the CIIRP. Efforts to reduce hospital readmissions should consider patient functional status as an important and potentially modifiable risk factor.
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Affiliation(s)
- Erik H Hoyer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD.
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Hazlitt M, Hill JB, Gunter OL, Guillamondegui OD. Disparities in trauma: the impact of socioeconomic factors on outcomes following traumatic hollow viscus injury. J Surg Res 2013; 191:6-11. [PMID: 24731764 DOI: 10.1016/j.jss.2013.05.052] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 05/06/2013] [Accepted: 05/10/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND This piece aims to examine the relationships between hollow viscus injury (HVI) and socioeconomic factors in determining outcomes. HVI has well-defined injury patterns with complex postoperative convalescence and morbidity, representing an ideal focus for identifying potential disparities among a homogeneous injury population. MATERIALS AND METHODS A retrospective review included patients admitted to a level I trauma center with HVI from 2000-2009, as identified in the Trauma Registry of the American College of Surgeons. Patients with concomitant significant solid organ or vasculature injury were excluded. US Census (2000) median household income by zip code was used as socioeconomic proxy. Demographic and injury-related variables were also included. Endpoints were mortality and outcomes associated with HVI morbidity. RESULTS A total of 933 patients with HVI were identified and 256 met inclusion criteria. There were 23 deaths (9.0%), and mortality was not associated with race, gender, income, or payer source. However, lower median household income was significantly associated with longer intervals to ostomy takedown (P = 0.032). Additionally, private payers had significantly lower rates of anastomotic leak (0% [0/73] versus 7.1% [13/183], P = 0.019) and fascial dehiscence (5.5% [4/73] versus 16.9% [31/183], P = 0.016), while self-payers had significantly higher rates of abscess formation, both overall (24% [24/100] versus 10.2% [16/156], P = 0.004) and among penetrating injuries (27.4% [23/84] versus 13.6% [12/88], P = 0.036). CONCLUSIONS Socioeconomic status may not impact overall mortality among trauma patients with hollow viscus injuries, but private insurance appears to be protective of morbidity related to anastomotic leak, fascial dehiscence, and abscess formation. This supports that socioeconomic disparity may exist within long-term outcomes, particularly regarding payer source.
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Affiliation(s)
- Melissa Hazlitt
- Division of Trauma, Department of Surgery, Meharry Medical College, Nashville, Tennessee
| | - J Bradford Hill
- Division of Trauma, Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Oliver L Gunter
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Oscar D Guillamondegui
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee.
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Huang KT, Hazzard MA, Babu R, Ugiliweneza B, Grossi PM, Huh BK, Roy LA, Patil C, Boakye M, Lad SP. Insurance Disparities in the Outcomes of Spinal Cord Stimulation Surgery. Neuromodulation 2013; 16:428-34; discussion 434-5. [DOI: 10.1111/ner.12059] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 02/14/2013] [Accepted: 03/05/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Kevin T. Huang
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Matthew A. Hazzard
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Ranjith Babu
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Beatrice Ugiliweneza
- Department of Neurosurgery; Center for Neurosurgical Outcomes Research; Maxine Dunitz Neurosurgical Institute; Cedars-Sinai Medical Center; Los Angeles CA USA
| | - Peter M. Grossi
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Billy K. Huh
- Department of Anesthesia; Divison of Pain; Duke University Medical Center; Durham NC USA
| | - Lance A. Roy
- Department of Anesthesia; Divison of Pain; Duke University Medical Center; Durham NC USA
| | - Chirag Patil
- Department of Neurosurgery; Center for Neurosurgical Outcomes Research; Maxine Dunitz Neurosurgical Institute; Cedars-Sinai Medical Center; Los Angeles CA USA
| | - Maxwell Boakye
- Department of Neurosurgery; University of Louisville; Louisville KY USA
- Department of Neurosurgery; Robley Rex VA Medical Center; Louisville KY USA
| | - Shivanand P. Lad
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
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Sammon J, Trinh VQ, Ravi P, Sukumar S, Gervais MK, Shariat SF, Larouche A, Tian Z, Kim SP, Kowalczyk KJ, Hu JC, Menon M, Karakiewicz PI, Trinh QD, Sun M. Health care-associated infections after major cancer surgery. Cancer 2013; 119:2317-24. [DOI: 10.1002/cncr.28027] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 01/20/2013] [Accepted: 01/24/2013] [Indexed: 02/03/2023]
Affiliation(s)
- Jesse Sammon
- Vattikuti Urology Institute; Henry Ford Health system; Detroit Michigan
| | - Vincent Q. Trinh
- Cancer Prognostics and Health Outcomes Unit; University of Montreal Health Center; Montreal Quebec, Montreal Canada
| | - Praful Ravi
- Vattikuti Urology Institute; Henry Ford Health system; Detroit Michigan
| | - Shyam Sukumar
- Vattikuti Urology Institute; Henry Ford Health system; Detroit Michigan
| | - Mai-Kim Gervais
- Division of General Surgery; University of Montreal Health Center; Montreal Quebec Canada
| | - Shahrokh F. Shariat
- Department of Urology; Weill Medical College of Cornell University; New York New York
| | - Alexandre Larouche
- Cancer Prognostics and Health Outcomes Unit; University of Montreal Health Center; Montreal Quebec, Montreal Canada
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit; University of Montreal Health Center; Montreal Quebec, Montreal Canada
| | - Simon P. Kim
- Department of Urology; Mayo Clinic; Rochester New York
| | - Keith J. Kowalczyk
- Department of Urology; Georgetown University Hospital; Washington District of Columbia
| | - Jim C. Hu
- Department of Urology; David Geffen School of Medicine; University of California-Los Angeles; Los Angeles California
| | - Mani Menon
- Vattikuti Urology Institute; Henry Ford Health system; Detroit Michigan
| | - Pierre I. Karakiewicz
- Cancer Prognostics and Health Outcomes Unit; University of Montreal Health Center; Montreal Quebec, Montreal Canada
| | - Quoc-Dien Trinh
- Vattikuti Urology Institute; Henry Ford Health system; Detroit Michigan
- Cancer Prognostics and Health Outcomes Unit; University of Montreal Health Center; Montreal Quebec, Montreal Canada
| | - Maxine Sun
- Cancer Prognostics and Health Outcomes Unit; University of Montreal Health Center; Montreal Quebec, Montreal Canada
- Department of Public Health; Faculty of Medicine; University of Montreal; Montreal Quebec Canada
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Aynardi M, Jacovides CL, Huang R, Mortazavi SMJ, Parvizi J. Risk factors for early mortality following modern total hip arthroplasty. J Arthroplasty 2013; 28:517-20. [PMID: 23142452 DOI: 10.1016/j.arth.2012.06.040] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 06/26/2012] [Accepted: 06/26/2012] [Indexed: 02/01/2023] Open
Abstract
The aim of this study was to evaluate the incidence of early mortality and identify risk factors for early death following modern uncemented THA. Between 2000 and 2006, we identified patients who died within 90days of THA. Demographics, comorbidities, laboratory studies, and complications were analyzed as risk factors for mortality. 38 of 8261 patients undergoing THA (0.46%) died within 90days postoperatively. Of these, 26% were due to myocardial infarction. Multivariate analysis revealed Charlson index >3, peripheral vascular disease, elevated postoperative glucose, and abnormal postoperative cardiac studies as independent predictors of early mortality following THA. Caution should be taken in patients with increased comorbidities, PVD, perioperative hyperglycemia, and impaired renal function in order to reduce mortality following THA.
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Affiliation(s)
- Michael Aynardi
- Rothman Institute of Orthopedics at Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
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207
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Frakt AB, Carroll AE. Sound policy trumps politics: states should expand Medicaid. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2013; 38:165-178. [PMID: 23052687 DOI: 10.1215/03616878-1898839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
By virtue of the Supreme Court's decision on the constitutionality of the Patient Protection and Affordable Care Act, states may reject the law's expansion of Medicaid without losing all Medicaid funding from the federal government. The Court's ruling potentially permits a range of Medicaid options for states, including some that may be very attractive from state officials' political perspectives. In the context of the presidential campaign, the uncompensated care problem, and their concerns about costs of expansion, state officials are weighing their options, and some have already pledged to opt out of expansion. We argue that despite the politics, expansion is in fact good for patients, providers, and taxpayers, and states should therefore comply.
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Wasserstein D, Dwyer T, Gandhi R, Austin PC, Mahomed N, Ogilvie-Harris D. A matched-cohort population study of reoperation after meniscal repair with and without concomitant anterior cruciate ligament reconstruction. Am J Sports Med 2013; 41:349-55. [PMID: 23263297 DOI: 10.1177/0363546512471134] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Evidence for the success of a meniscal repair performed alone versus combined with anterior cruciate ligament reconstruction (ACLR) is equivocal. No large-scale comparative studies exist regarding this issue. HYPOTHESIS In the general population, meniscal repair in a presumed stable knee has the same rate of reoperation as meniscal repair performed with ACLR. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS All meniscal repairs performed with ACLR in Ontario, Canada, between July 2003 and March 2008 in patients aged 15 to 60 years were identified using administrative billing, diagnostics, and procedural coding. This cohort was matched 1:1 for sex, age, and calendar year of surgery with a cohort of patients who underwent meniscal repair alone. The McNemar test of matched pairs was used to compare reoperation rates (debridement or repair) within 2 years of the index procedure. Conditional logistic regression analysis was used to identify potential risk factors for reoperation among unmatched patient (socioeconomic status surrogate, comorbidity) and provider (surgeon volume, academic hospital status) factors. RESULTS Of 1332 patients who underwent meniscal repair and ACLR, 1239 (93%) were matched with patients who underwent meniscal repair alone. The rate of meniscal reoperation was 9.7% in the combined cohort compared with 16.7% in the repair alone cohort (P < .0001). In the regression analysis, only ACLR was protective against meniscal reoperation (odds ratio, 0.57; P < .0001). Surgeon volume of meniscal repair did not influence outcome. CONCLUSION A meniscal repair performed in conjunction with ACLR carries a 7% absolute and 42% relative risk reduction of reoperation after 2 years compared with isolated meniscal repair.
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Affiliation(s)
- David Wasserstein
- University of Toronto Orthopaedic Sports Medicine at Women's College Hospital, 399 Bathurst St., 437, 1 East Wing, Toronto, ON, Canada, M5T2S8.
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Stone ML, LaPar DJ, Mulloy DP, Rasmussen SK, Kane BJ, McGahren ED, Rodgers BM. Primary payer status is significantly associated with postoperative mortality, morbidity, and hospital resource utilization in pediatric surgical patients within the United States. J Pediatr Surg 2013; 48:81-7. [PMID: 23331797 PMCID: PMC3921619 DOI: 10.1016/j.jpedsurg.2012.10.021] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 10/13/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Current healthcare reform efforts have highlighted the potential impact of insurance status on patient outcomes. The influence of primary payer status (PPS) within the pediatric surgical patient population remains unknown. The purpose of this study was to examine risk-adjusted associations between PPS and postoperative mortality, morbidity, and resource utilization in pediatric surgical patients within the United States. METHODS A weighted total of 153,333 pediatric surgical patients were evaluated using the national Kids' Inpatient Database (2003 and 2006): appendectomy, intussusception, decortication, pyloromyotomy, congenital diaphragmatic hernia repair, and colonic resection for Hirschsprung's disease. Patients were stratified according to PPS: Medicare (n=180), Medicaid (n=51,862), uninsured (n=12,539), and private insurance (n=88,753). Multivariable hierarchical regression modeling was utilized to evaluate risk-adjusted associations between PPS and outcomes. RESULTS Overall median patient age was 12 years, operations were primarily non-elective (92.4%), and appendectomies accounted for the highest proportion of cases (81.3%). After adjustment for patient, hospital, and operation-related factors, PPS was independently associated with in-hospital death (p<0.0001) and postoperative complications (p<0.02), with increased risk for Medicaid and uninsured populations. Moreover, Medicaid PPS was also associated with greater adjusted lengths of stay and total hospital charges (p<0.0001). Importantly, these results were dependent on operation type. CONCLUSIONS Primary payer status is associated with risk-adjusted postoperative mortality, morbidity, and resource utilization among pediatric surgical patients. Uninsured patients are at increased risk for postoperative mortality while Medicaid patients accrue greater morbidity, hospital lengths of stay, and total charges. These results highlight a complex interaction between socioeconomic and patient-related factors, and primary payer status should be considered in the preoperative risk stratification of pediatric patients.
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Affiliation(s)
- Matthew L. Stone
- Department of Surgery, The University of Virginia, Charlottesville, Virginia, USA
| | - Damien J. LaPar
- Department of Surgery, The University of Virginia, Charlottesville, Virginia, USA
| | - Daniel P. Mulloy
- Department of Surgery, The University of Virginia, Charlottesville, Virginia, USA
| | - Sara K. Rasmussen
- Division of Pediatric Surgery, The University of Virginia, Charlottesville, Virginia, USA
| | - Bartholomew J. Kane
- Division of Pediatric Surgery, The University of Virginia, Charlottesville, Virginia, USA
| | - Eugene D. McGahren
- Division of Pediatric Surgery, The University of Virginia, Charlottesville, Virginia, USA
| | - Bradley M. Rodgers
- Division of Pediatric Surgery, The University of Virginia, Charlottesville, Virginia, USA
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Disparities in Outcomes for Hispanic Patients Undergoing Endovascular and Open Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2013; 27:29-37. [DOI: 10.1016/j.avsg.2012.06.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 05/24/2012] [Accepted: 06/27/2012] [Indexed: 11/19/2022]
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Neureuther SJ, Nagpal K, Greenbaum A, Cosgrove JM, Farkas DT. The effect of insurance status on outcomes after laparoscopic cholecystectomy. Surg Endosc 2012; 27:1761-5. [PMID: 23247740 DOI: 10.1007/s00464-012-2675-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Accepted: 10/22/2012] [Indexed: 12/25/2022]
Abstract
BACKGROUND Part of the ongoing healthcare debate is the care of uninsured patients. A common theory is that without regular outpatient care, these patients present to the hospital in the late stages of disease and therefore have worse outcomes. The purpose of this study was to evaluate any differences in outcomes after laparoscopic cholecystectomies between insured and uninsured patients. METHODS We reviewed all laparoscopic cholecystectomies (LC) done in our institution between 2006 and 2009. Patients were divided into two groups: insured patients (IP) and uninsured patients (UIP). Outcomes, including conversion and complication rates and postoperative length of stay (LOS), were collected and statistically analyzed using χ(2) and ANOVA tests. RESULTS There were 1,090 LCs done during the study period: 944 patients (86.6 %) were insured (IP) and 146 (13.4 %) were uninsured (UIP). In the IP group there were 63/944 (6.7 %) conversions and 59/944 (6.3 %) complications, while in the UIP group there were 15/146 (10.3 %) conversions and 12/146 (8.2 %) complications. There was no statistically significant difference in either of these categories. Mean (±SD) LOS was 1.73 ± 4.34 days for the IP group and 2.72 ± 4.35 days for the UIP group (p = 0.010, ANOVA). Uninsured patients were much more likely to have emergency surgery (99.3 % vs. 47.9 %, p < 0.001, χ(2)). CONCLUSIONS In our study group, being uninsured did not correlate with having a higher rate of conversion or complications. However, more uninsured patients had their surgery done emergently, and this led to significantly longer lengths of stay. Further research is necessary to study the cost impact of these findings and to see whether insuring these patients can lead to changes in their outcomes.
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Affiliation(s)
- Samantha J Neureuther
- Department of Surgery, Bronx-Lebanon Hospital Center, Albert Einstein College of Medicine, 1650 Selwyn Ave, Bronx, NY 10457, USA
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LaPar DJ, Stukenborg GJ, Guyer RA, Stone ML, Bhamidipati CM, Lau CL, Kron IL, Ailawadi G. Primary payer status is associated with mortality and resource utilization for coronary artery bypass grafting. Circulation 2012; 126:S132-9. [PMID: 22965973 DOI: 10.1161/circulationaha.111.083782] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Medicaid and uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes after coronary artery bypass grafting (CABG) in the United States is dependent on primary payer status. METHODS AND RESULTS From 2003 to 2007, 1,250,619 isolated CABG operations were evaluated using the Nationwide Inpatient Sample (NIS) database. Patients were stratified by primary payer status: Medicare, Medicaid, uninsured, and private insurance. Hierarchical multiple regression models were applied to assess the effect of primary payer status on postoperative outcomes. Unadjusted mortality for Medicare (3.3%), Medicaid (2.4%), and uninsured (1.9%) patients were higher compared with private insurance patients (1.1%, P<0.001). Unadjusted length of stay was longest for Medicaid patients (10.9 ± 0.04 days) and shortest for private insurance patients (8.0 ± 0.01 days, P<0.001). Medicaid patients accrued the highest unadjusted total costs ($113 380 ± 386, P<0.001). Importantly, after controlling for patient risk factors, income, hospital features, and operative volume, Medicaid (odds ratio, 1.82; P<0.001) and uninsured (odds ratio, 1.62; P<0.001) payer status independently conferred the highest adjusted odds of in-hospital mortality. In addition, Medicaid payer status was associated with the longest adjusted length of stay and highest adjusted total costs (P<0.001). CONCLUSIONS Medicaid and uninsured payer status confers increased risk adjusted in-hospital mortality for patients undergoing coronary artery bypass grafting operations. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors. Possible explanations include delays in access to care or disparate differences in health maintenance.
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Affiliation(s)
- Damien J LaPar
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
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Causality in administrative datasets. J Crohns Colitis 2012; 6:867; author reply 868. [PMID: 22609183 DOI: 10.1016/j.crohns.2012.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Accepted: 04/23/2012] [Indexed: 02/08/2023]
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Trinh QD, Sammon J, Jhaveri J, Sun M, Ghani KR, Schmitges J, Jeong W, Peabody JO, Karakiewicz PI, Menon M. Variations in the quality of care at radical prostatectomy. Ther Adv Urol 2012; 4:61-75. [PMID: 22496709 DOI: 10.1177/1756287211433187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Postoperative morbidity and mortality is low following radical prostatectomy (RP), though not inconsequential. Due to the natural history of the disease process, the implications of treatment on long-term oncologic control and functional outcomes are of increased significance. Structures, processes and outcomes are the three main determinants of quality of RP care and provide the framework for this review. Structures affecting quality of care include hospital and surgeon volume, hospital teaching status and patient insurance type. Process determinants of RP care have been poorly studied, by and large, but there is a developing trend toward the performance of randomized trials to assess the merits of evolving RP techniques. Finally, the direct study of RP outcomes has been particularly controversial and includes the development of quality of life measurement tools, combined outcomes measures, and the use of utilities to measure operative success based on individual patient priority.
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Primary payer status is associated with the use of nerve block placement for ambulatory orthopedic surgery. Reg Anesth Pain Med 2012; 37:254-61. [PMID: 22430024 DOI: 10.1097/aap.0b013e31824889b6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Although more than 30 million patients in the United States undergo ambulatory surgery each year, it remains unclear what percentage of these patients receive a perioperative nerve block. We reviewed data from the 2006 National Survey of Ambulatory Surgery to determine the demographic, socioeconomic, geographic, and clinical factors associated with the likelihood of nerve block placement for ambulatory orthopedic surgery. The primary outcome of interest was the association between primary method of payment and likelihood of nerve block placement. In addition, we examined the association between type of surgical procedures, patient demographics, and hospital characteristics with the likelihood of receiving a nerve block. METHODS This cross-sectional study reviewed 6000 orthopedic anesthetics from the 2006 National Survey of Ambulatory Surgery data set, which accounted for more than 3.9 million orthopedic anesthetics when weighted. The primary outcome of this study addressed the likelihood of receiving a nerve block for orthopedic ambulatory surgery according to the patient's primary method of payment. Secondary end points included differences in demographics, surgical procedures, adverse effects, complications, recovery profile, anesthesia staffing model, and total perioperative charges in those with and without nerve block. RESULTS Overall, 14.9% of anesthetics in this sample involved a peripheral nerve block. Length of time in postoperative recovery, total perioperative time, and total charges were less for those receiving nerve blocks. Patients were more likely to receive a nerve block if their procedures were performed in metropolitan service areas (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.19-2.91; P = 0.007) or in freestanding surgical facilities (OR, 2.27; 95% CI, 1.74-2.96; P < 0.0001) and if payment for their surgery was supported by government programs (OR, 2.5; 95% CI, 1.01-6.21; P = 0.048) or private insurance (OR, 2.62; 95% CI, 1.12-6.13; P = 0.03) versus self-pay or charity care. CONCLUSIONS For patients receiving ambulatory orthopedic surgery in the United States, our results suggest that geographic and socioeconomic factors are associated with different likelihoods of perioperative peripheral nerve block placement.
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Taghavi S, Jayarajan SN, Duran JM, Gaughan JP, Pathak A, Santora TA, Willis AI, Goldberg AJ. Does payer status matter in predicting penetrating trauma outcomes? Surgery 2012; 152:227-31. [DOI: 10.1016/j.surg.2012.05.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 05/14/2012] [Indexed: 10/28/2022]
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LaPar DJ, Bhamidipati CM, Lau CL, Jones DR, Kozower BD. The Society of Thoracic Surgeons General Thoracic Surgery Database: establishing generalizability to national lung cancer resection outcomes. Ann Thorac Surg 2012; 94:216-21; discussion 221. [PMID: 22608716 DOI: 10.1016/j.athoracsur.2012.03.054] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 03/08/2012] [Accepted: 03/12/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Society of Thoracic Surgeons General Thoracic Surgery Database (GTDB) has demonstrated outstanding results for lung cancer resection. However, whether the GTDB results are generalizable nationwide is unknown. The purpose of this study was to establish the generalizability of the GTDB by comparing lung cancer resection results with those of the Nationwide Inpatient Sample (NIS), the largest all-payer inpatient database in the United States. METHODS From 2002 to 2008, primary lung cancer resection outcomes were compared between the GTDB (n = 19,903) and the NIS (n = 246,469). Primary outcomes were the proportion of procedures performed nationally that were captured in the GTDB and differences in mortality rates and hospital length of stay. Observed differences in patient characteristics, operative procedures, and postoperative events were also analyzed. RESULTS Annual GTDB lung cancer resection volume has increased over time but only captures an estimated 8% of resections performed nationally. The GTDB and NIS databases had similar median patient age (67 vs 68 years) and female sex (50% vs 49%), lobectomy was the most common procedure (64.7% vs 79.7%; p < 0.001), and pneumonectomies were uncommon (6.3% vs 7.2%; p < 0.001). Compared with NIS, the GTDB had significantly lower unadjusted discharge mortality rates (1.8% vs 3.0%), median length of stay (5.0 vs 7.0 days; p < 0.001), and postoperative pulmonary complication rates (18.5% vs 23.6%, p < 0.001). CONCLUSIONS The GTDB represents a small percentage of the lung cancer resections performed nationally and reports significantly lower mortality rates and shorter hospital length of stay than national results. The GTDB is not broadly generalizable. These results establish a benchmark for future GTDB comparisons and highlight the importance of increasing participation in the database.
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Affiliation(s)
- Damien J LaPar
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia 22908, USA
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Miller T, Capretta JC, Turner GM. Why the (un)affordable care act should be repealed and replaced. Am J Med 2012; 125:e1-4. [PMID: 22482851 DOI: 10.1016/j.amjmed.2012.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 01/01/2012] [Accepted: 01/02/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Tom Miller
- American Enterprise Institute, Washington, DC, USA
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219
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Robinson CN, Balentine CJ, Sansgiry S, Berger DH. Disparities in the use of minimally invasive surgery for colorectal disease. J Gastrointest Surg 2012; 16:897-903; discussion 903-4. [PMID: 22411487 DOI: 10.1007/s11605-012-1844-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 02/10/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Morbidity and mortality rates for major surgical procedures are decreased in high-volume hospitals (HVH). Additionally, HVH are often leaders in the utilization of novel surgical technology such as minimally invasive surgery (MIS). Although HVH often serve diverse patient populations, it is unknown if there are disparities in the application of new surgical technologies within these hospitals. We sought to determine if ethnic and socioeconomic disparities in the use of MIS for colorectal disease exist at HVH. METHODS Laparoscopic and open colectomies performed at HVH were identified using the 2008 Nationwide Inpatient Sample database. ICD-9 codes were used to identify MIS colorectal resections. Multiple logistic regression including ethnic and socioeconomic variables were used to identify independent predictive factors for undergoing MIS. RESULTS A total of 211,862 colorectal resections were performed at HVH in 2008. Only 16,637 (7.3%) colorectal resections were performed using MIS. When evaluating racial and socioeconomic factors, patients within the highest income quartile were more likely to undergo MIS than those in the lowest income groups. In addition, patients with Medicaid and uninsured patients were significantly less likely to undergo MIS compared to patients with private insurance. Lastly, race was not a significant predictive factor for undergoing MIS for colorectal disease at HVH. CONCLUSION There are significant socioeconomic disparities in the use of MIS for colorectal disease at HVH. Future studies should be aimed at identifying access barriers to MIS in the treatment of colorectal disease.
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Affiliation(s)
- Celia N Robinson
- Operative Care Line, The Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd. 5A 350, Mailing code OCL 112, Houston, TX 77030, USA.
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220
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Maruthappu M, Ologunde R, Gunarajasingam A. Is Health Care a Right? Health Reforms in the USA and their Impact Upon the Concept of Care. Ann Med Surg (Lond) 2012; 2:15-7. [PMID: 25973184 PMCID: PMC4326121 DOI: 10.1016/s2049-0801(13)70021-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 12/16/2012] [Indexed: 12/01/2022] Open
Abstract
In 2008 United States President Barack Obama declared that health care “should be a right for every American”.1 This statement, although noble, does not reflect US healthcare statistics in recent times, with the number of uninsured reaching over 50 million in 2010.2 Such disparity has sparked a political drive towards change, and the introduction of the Patient Protection and Affordable Care Act (PPACA).3 These changes have been highly polemical, raising the fundamental question of whether health care is a right; a contract between the nation and its inhabitants granted at birth, or an entitlement; a privilege that must be earned as opposed to universally provided. Access to healthcare in the US is mediated by insurance coverage, either in the form of private or employer based cover, which may be government based for public sector employees or private for private sector employees. The majority of spending on healthcare however, comes from government expenditure on health programs such as Medicare, Medicaid, Tricare, and the State Children's Health Insurance Program (SCHIP).4 Medicare is a federal government funded social insurance program that provides health insurance to people aged 65 and older, younger people with disabilities, and those with end stage renal failure requiring dialysis. Medicaid is a means tested insurance coverage program for individuals with low incomes and their families, and is jointly funded by state and federal governments. Tricare is a healthcare program that provides healthcare insurance for military personnel, retirees, and their dependents. The SCHIP provides states with federal government funding to provide health insurance to children from families with modest incomes that do not qualify for Medicaid. As such, although the majority of the US population is insured by federal, state, employer, or private health insurance, the remainders go uninsured.
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Dasenbrock HH, Wolinsky JP, Sciubba DM, Witham TF, Gokaslan ZL, Bydon A. The impact of insurance status on outcomes after surgery for spinal metastases. Cancer 2012; 118:4833-41. [DOI: 10.1002/cncr.27388] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 11/23/2011] [Indexed: 11/08/2022]
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Allen JG, Weiss ES, Arnaoutakis GJ, Russell SD, Baumgartner WA, Shah AS, Conte JV. Insurance and education predict long-term survival after orthotopic heart transplantation in the United States. J Heart Lung Transplant 2012; 31:52-60. [DOI: 10.1016/j.healun.2011.07.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Revised: 07/26/2011] [Accepted: 07/28/2011] [Indexed: 11/26/2022] Open
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Wu XC, Lund MJ, Kimmick GG, Richardson LC, Sabatino SA, Chen VW, Fleming ST, Morris CR, Huang B, Trentham-Dietz A, Lipscomb J. Influence of race, insurance, socioeconomic status, and hospital type on receipt of guideline-concordant adjuvant systemic therapy for locoregional breast cancers. J Clin Oncol 2011; 30:142-50. [PMID: 22147735 DOI: 10.1200/jco.2011.36.8399] [Citation(s) in RCA: 139] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE For breast cancer, guidelines direct the delivery of adjuvant systemic therapy on the basis of lymph node status, histology, tumor size, grade, and hormonal receptor status. We explored how race/ethnicity, insurance, census tract-level poverty and education, and hospital Commission on Cancer (CoC) status were associated with the receipt of guideline-concordant adjuvant systemic therapy. METHODS Locoregional breast cancers diagnosed in 2004 (n = 6,734) were from the National Program of Cancer Registries-funded seven-state Patterns of Care study of the Centers for Disease Control and Prevention. Predictors of guideline-concordant (receiving/not receiving) adjuvant systemic therapy, according to National Comprehensive Cancer Network Guidelines, were explored by logistic regression. RESULTS Overall, 35% of women received nonguideline chemotherapy, 12% received nonguideline regimens, and 20% received nonguideline hormonal therapy. Significant predictors of nonguideline chemotherapy included Medicaid insurance (odds ratio [OR], 0.66; 95% CI, 0.50 to 0.86), high-poverty areas (OR, 0.77; 95% CI, 0.62 to 0.96), and treatment at non-CoC hospitals (OR, 0.69; 95% CI, 0.56 to 0.85), with adjustment for age, registry, and clinical variables. Predictors of nonguideline regimens among chemotherapy recipients included lack of insurance (OR, 0.47; 95% CI, 0.25 to 0.92), high-poverty areas (OR, 0.71; 95% CI, 0.51 to 0.97), and low-education areas (OR, 0.65; 95% CI, 0.48 to 0.89) after adjustment. Living in high-poverty areas (OR, 0.78; 95% CI, 0.64 to 0.96) and treatment at non-CoC hospitals (OR, 0.68; 95% CI, 0.55 to 0.83) predicted nonguideline hormonal therapy after adjustment. ORs for poverty, education, and insurance were attenuated in the full models. CONCLUSION Sociodemographic and hospital factors are associated with guideline-concordant use of systemic therapy for breast cancer. The identification of modifiable factors that lead to nonguideline treatment may reduce disparities in breast cancer survival.
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Affiliation(s)
- Xiao-Cheng Wu
- Louisiana State University Health Sciences Center, 1615 Poydras St, Suite 1400, New Orleans, LA 70112, USA.
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El-Sayed AM, Ziewacz JE, Davis MC, Lau D, Siddiqi HK, Zamora-Berridi GJ, Sullivan SE. Insurance Status and Inequalities in Outcomes After Neurosurgery. World Neurosurg 2011; 76:459-66. [DOI: 10.1016/j.wneu.2011.03.051] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 02/15/2011] [Accepted: 03/31/2011] [Indexed: 10/14/2022]
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Abdo A, Trinh QD, Sun M, Schmitges J, Bianchi M, Sammon J, Shariat SF, Sukumar S, Zorn K, Jeldres C, Perrotte P, Rogers CG, Peabody JO, Menon M, Karakiewicz PI. The effect of insurance status on outcomes after partial nephrectomy. Int Urol Nephrol 2011; 44:343-51. [PMID: 21894468 DOI: 10.1007/s11255-011-0056-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 08/23/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Privately insured patients may have favorable health outcomes when compared to those covered by federally funded initiatives. This study explored the effect of insurance status on five short-term outcomes after partial nephrectomy (PN). METHODS Within the Health Care Utilization Project Nationwide Inpatient Sample (NIS), we focused on PNs performed between 1998 and 2007. We tested the rates of in-hospital mortality, blood transfusions, prolonged length of stay, as well as intraoperative and postoperative complications, stratified according to insurance status. Multivariable logistic regression analyses fitted with general estimation equations for clustering among hospitals further adjusted for confounding factors. RESULTS Overall, 8,513 PNs were identified. Of those, most patients were privately insured (53.5%), followed by Medicare (37.5%), uninsured (4.6%) and Medicaid (4.4%). Medicare and Medicaid patients had higher rates of transfusions (P < 0.001) and overall postoperative complications (P < 0.001). In multivariable analyses, when compared to privately insured patients, Medicaid patients had higher rates of transfusions (OR = 1.91, P < 0.001) and prolonged length of stay (OR = 1.49, P < 0.001). Medicare patients had higher rates of overall postoperative complications (OR = 1.24, P = 0.015) and length of stay beyond the median (OR = 1.4, P < 0.001). CONCLUSION Patients with private insurance undergoing PN have better short-term outcomes, when compared to their publicly insured counterparts.
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Affiliation(s)
- Al'a Abdo
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, 1058, rue St-Denis, Montreal, QC, H2X 3J4, Canada.
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A Population-Based Analysis of Temporal Perioperative Complication Rates After Minimally Invasive Radical Prostatectomy. Eur Urol 2011; 60:564-71. [DOI: 10.1016/j.eururo.2011.06.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 06/16/2011] [Indexed: 11/18/2022]
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Trinh QD, Schmitges J, Sun M, Sammon J, Shariat SF, Zorn K, Sukumar S, Bianchi M, Perrotte P, Graefen M, Rogers CG, Peabody JO, Menon M, Karakiewicz PI. Morbidity and mortality of radical prostatectomy differs by insurance status. Cancer 2011; 118:1803-10. [DOI: 10.1002/cncr.26475] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Revised: 06/07/2011] [Accepted: 07/11/2011] [Indexed: 11/11/2022]
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LaPar DJ, Bhamidipati CM, Harris DA, Kozower BD, Jones DR, Kron IL, Ailawadi G, Lau CL. Gender, race, and socioeconomic status affects outcomes after lung cancer resections in the United States. Ann Thorac Surg 2011; 92:434-9. [PMID: 21704976 PMCID: PMC3282148 DOI: 10.1016/j.athoracsur.2011.04.048] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 04/06/2011] [Accepted: 04/11/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND The effect of gender, race, and socioeconomic status on contemporary outcomes after lung cancer resections has not been comprehensively evaluated across the United States. We hypothesized that risk-adjusted outcomes for lung cancer resections would not be influenced by these factors. METHODS From 2003 to 2007, 129,207 patients undergoing lung cancer resections were evaluated using the Nationwide Inpatient Sample (NIS) database. Multiple regression analysis was used to estimate the effects of gender, race, and socioeconomic status on risk-adjusted outcomes. RESULTS Average patient age was 66.8±10.5 years. Women accounted for 5.0% of the total study population. Among racial groups, whites underwent the largest majority of operations (86.2%), followed by black (6.9%) and Hispanic (2.8%) races. Overall the incidence of mortality was 2.9%, postoperative complications were 30.4%, and pulmonary complications were 22.0%. Female gender, race, and mean income were all multivariate correlates of adjusted mortality and morbidity. Black patients incurred decreased risk-adjusted morbidity and mortality compared with white patients. Hispanics and Asians demonstrated decreased risk-adjusted complication rates. Importantly low income status independently increased the adjusted odds of mortality. CONCLUSIONS Female gender is associated with decreased mortality and morbidity after lung cancer resections. Complication rates are lower for black, Hispanic, and Asian patients. Low socioeconomic status increases the risk of in-hospital death. These factors should be considered during patient risk stratification for lung cancer resection.
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Affiliation(s)
- Damien J LaPar
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia Health System, Charlottesville, Virginia 22908, USA
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Affiliation(s)
- Austin Frakt
- Health Care Financing and Economics, VA Boston Healthcare System, and Boston University, Boston, USA
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230
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Lapar DJ, Bhamidipati CM, Walters DM, Stukenborg GJ, Lau CL, Kron IL, Ailawadi G. Primary payer status affects outcomes for cardiac valve operations. J Am Coll Surg 2011; 212:759-67. [PMID: 21398153 DOI: 10.1016/j.jamcollsurg.2010.12.050] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 12/14/2010] [Accepted: 12/14/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND Disparities in health care have been reported among various patient populations, and the uninsured and Medicaid populations are a major focus of current health care reform. The objective of this study was to examine the influence of primary payer status on outcomes after cardiac valve operations in the United States. METHODS From 2003 to 2007, 477,932 patients undergoing cardiac valve operations were evaluated using discharge data from the Nationwide Inpatient Sample database. Records were stratified by primary payer status: Medicare (n = 57,249, age = 74.0 ± 0.02 years), Medicaid (n = 5,868, age = 41.2 ± 0.13 years), uninsured (n = 2,349, age = 49.7 ± 0.15 years), and private insurance (n = 31,808, age = 53.3 ± 0.04 years). Multivariate regression models were applied to assess the independent effect of payer status on in-hospital outcomes. RESULTS Preoperative patient risk factors were more common among Medicare and Medicaid populations. Unadjusted mortality and complication rates for Medicare (6.9%, 36.6%), Medicaid (5.7%, 31.4%) and uninsured (5.2%, 31.4%) patient groups were higher compared with private insurance groups (2.9%, 29.9%; p < 0.001). In addition, mortality was lowest for patients with private insurance for all types of valve operations. Medicaid patients accrued the longest unadjusted hospital length of stay and highest total hospital costs compared with other payer groups (p < 0.001). Importantly, after risk adjustment, uninsured and Medicaid payer status conferred the highest odds of risk-adjusted mortality and morbidity compared with private insurance status, which were higher than those for Medicare. CONCLUSIONS Uninsured and Medicaid payer status is associated with increased risk-adjusted in-hospital mortality and morbidity among patients undergoing cardiac valve operations compared with Medicare and private insurance. In addition, Medicaid patients accrued the longest hospital stays and highest total costs. Primary payer status should be considered as an independent risk factor during preoperative risk stratification and planning.
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Affiliation(s)
- Damien J Lapar
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
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