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Feeney ME, Law AC, Walkey AJ, Bosch NA. Variation in Use of Medications for Opioid Use Disorder in Critically Ill Patients Across the United States. Crit Care Med 2024; 52:e365-e375. [PMID: 38501933 PMCID: PMC11176030 DOI: 10.1097/ccm.0000000000006257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
OBJECTIVES To describe practice patterns surrounding the use of medications to treat opioid use disorder (MOUD) in critically ill patients. DESIGN Retrospective, multicenter, observational study using the Premier AI Healthcare Database. SETTING The study was conducted in U.S. ICUs. PATIENTS Adult (≥ 18 yr old) patients with a history of opioid use disorder (OUD) admitted to an ICU between 2016 and 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 108,189 ICU patients (658 hospitals) with a history of OUD, 20,508 patients (19.0%) received MOUD. Of patients receiving MOUD, 13,745 (67.0%) received methadone, 2,950 (14.4%) received buprenorphine, and 4,227 (20.6%) received buprenorphine/naloxone. MOUD use occurred in 37.9% of patients who received invasive mechanical ventilation. The median day of MOUD initiation was hospital day 2 (interquartile range [IQR] 1-3) and the median duration of MOUD use was 4 days (IQR 2-8). MOUD use per hospital was highly variable (median 16.0%; IQR 10-24; range, 0-70.0%); admitting hospital explained 8.9% of variation in MOUD use. A primary admitting diagnosis of unintentional poisoning (aOR 0.41; 95% CI, 0.38-0.45), presence of an additional substance use disorder (aOR 0.66; 95% CI, 0.64-0.68), and factors indicating greater severity of illness were associated with reduced odds of receiving MOUD in the ICU. CONCLUSIONS In a large multicenter, retrospective study, there was large variation in the use of MOUD among ICU patients with a history of OUD. These results inform future studies seeking to optimize the approach to MOUD use during critical illness.
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Affiliation(s)
| | - Anica C. Law
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine School of Medicine, Boston, MA
| | - Allan J. Walkey
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine School of Medicine, Boston, MA
| | - Nicholas A. Bosch
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine School of Medicine, Boston, MA
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Lindenfeld Z, Franz B, Lai AY, Pagán JA, Fenstemaker C, Cronin CE, Chang JE. Barriers and Facilitators to Establishing Partnerships for Substance Use Disorder Care Transitions Between Safety-Net Hospitals and Community-Based Organizations. J Gen Intern Med 2024:10.1007/s11606-024-08883-8. [PMID: 38937366 DOI: 10.1007/s11606-024-08883-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The effectiveness of hospital-based transitional opioid programs (TOPs), which aim to connect patients with substance use disorders (SUD) to ongoing treatment in the community following initiation of medication for opioid use disorder (MOUD) treatment in the hospital, hinges on successful patient transitions. These transitions are enabled by strong partnerships between hospitals and community-based organizations (CBOs). However, no prior study has specifically examined barriers and facilitators to establishing SUD care transition partnerships between hospitals and CBOs. OBJECTIVE To identify barriers and facilitators to developing partnerships between hospitals and CBOs to facilitate care transitions for patients with SUDs. DESIGN Qualitative study using semi structured interviews conducted between November 2022-August 2023. PARTICIPANTS Staff and providers from hospitals affiliated with four safety-net health systems (n=21), and leaders and staff from the CBOs with which they had established partnerships (n=5). APPROACH Interview questions focused on barriers and facilitators to implementing TOPs, developing partnerships with CBOs, and successfully transitioning SUD patients from hospital settings to CBOs. KEY RESULTS We identified four key barriers to establishing transition partnerships: policy and philosophical differences between organizations, ineffective communication, limited trust, and a lack of connectivity between data systems. We also identified three facilitators to partnership development: strategies focused on building partnership quality, strategic staffing, and organizing partnership processes. CONCLUSIONS Our findings demonstrate that while multiple barriers to developing hospital-CBO partnerships exist, stakeholders can adopt implementation strategies that mitigate these challenges such as using mediators, cross-hiring, and focusing on mutually beneficial services, even within resource-limited safety-net settings. Policymakers and health system leaders who wish to optimize TOPs in their facilities should focus on adopting implementation strategies to support transition partnerships such as inadequate data collection and sharing systems.
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Affiliation(s)
- Zoe Lindenfeld
- Edward J. Bloustein School of Planning and Public Policy, Rutgers University, New Brunswick, NJ, 08901, USA.
| | - Berkeley Franz
- Heritage College of Osteopathic Medicine, The Institute to Advance Health Equity, Ohio University, 1 Ohio University, Athens, OH, 45701, USA
| | - Alden Yuanhong Lai
- Department of Public Health Policy and Management, School of Global Public Health, New York University, 708 Broadway, New York, NY, 10003, USA
| | - José A Pagán
- Department of Public Health Policy and Management, School of Global Public Health, New York University, 708 Broadway, New York, NY, 10003, USA
| | - Cheyenne Fenstemaker
- Heritage College of Osteopathic Medicine, The Institute to Advance Health Equity, Ohio University, 1 Ohio University, Athens, OH, 45701, USA
| | - Cory E Cronin
- College of Health Sciences and Professions, The Institute to Advance Health Equity, Ohio University, 1 Ohio University, Athens, OH, 45701, USA
| | - Ji Eun Chang
- Department of Public Health Policy and Management, School of Global Public Health, New York University, 708 Broadway, New York, NY, 10003, USA
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Lee JY, Pihl E, Kim HK, Russell T, Petrie BA, Lee H. Risk Factors for Suboptimal Colon Cancer Diagnosis and Management at a Safety-Net Hospital System. J Surg Res 2024; 301:127-135. [PMID: 38925099 DOI: 10.1016/j.jss.2024.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/07/2024] [Accepted: 05/16/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Colon cancer (CC) is the second leading cause of cancer-related deaths in the United States. Quality measures have been introduced by the American Gastroenterological Association and Commission on Cancer for optimal management of CC. In this study, we sought to identify factors that may hinder the timely diagnosis and treatment of CC at a safety-net hospital system. METHODS Retrospective chart review was performed for patients aged ≥18 y diagnosed with CC from 2018 to 2021. Primary outcomes were time from positive fecal immunochemical test to colonoscopy, time from diagnosis to surgery, and time from diagnosis to adjuvant chemotherapy. Secondary end points were demographic characteristics associated with suboptimal outcomes in any of the above measures. RESULTS One hundred ninety patients were diagnosed with nonmetastatic CC. The majority were Hispanic and non-English-speaking. 74.1% of patients with a positive fecal immunochemical test received a colonoscopy within 180 d. 59.6% of nonemergent cases received surgery within 60 d of diagnosis. 77% of those eligible received adjuvant chemotherapy within 120 d of diagnosis. No clinically significant demographic factor was associated with delay in colonoscopy, surgery, or adjuvant chemotherapy. Most frequent cause of delay in surgery (38.0%) was optimization of comorbidities. Most frequent cause of delay in adjuvant chemotherapy (71.4%) was delay in surgery itself. CONCLUSIONS No clinically significant demographic factor was associated with experiencing delays in diagnostic colonoscopy, surgery, or adjuvant chemotherapy.
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Affiliation(s)
- Ju Young Lee
- David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Erik Pihl
- Division of Colon and Rectal Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Hye Kwang Kim
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, Illinois
| | - Tara Russell
- Division of Colon and Rectal Surgery, Olive View-UCLA Medical Center, Sylmar, California
| | - Beverley A Petrie
- Division of Colon and Rectal Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Hanjoo Lee
- Division of Colon and Rectal Surgery, Harbor-UCLA Medical Center, Torrance, California.
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Ali K, Chervu NL, Sakowitz S, Bakhtiyar SS, Benharash P, Mohseni S, Keeley JA. Interhospital variation in the nonoperative management of acute cholecystitis. PLoS One 2024; 19:e0300851. [PMID: 38857278 PMCID: PMC11164333 DOI: 10.1371/journal.pone.0300851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/05/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Cholecystectomy remains the standard management for acute cholecystitis. Given that rates of nonoperative management have increased, we hypothesize the existence of significant hospital-level variability in operative rates. Thus, we characterized patients who were managed nonoperatively at normal and lower operative hospitals (>90th percentile). METHODS All adult admissions for acute cholecystitis were queried using the 2016-2019 Nationwide Readmissions Database. Centers were ranked by nonoperative rate using multi-level, mixed effects modeling. Hospitals in the top decile of nonoperative rate (>9.4%) were classified as Low Operative Hospitals (LOH; others:nLOH). Separate regression models were created to determine factors associated with nonoperative management at LOH and nLOH. RESULTS Of an estimated 418,545 patients, 9.9% were managed at 880 LOH. Multilevel modeling demonstrated that 20.6% of the variability was due to hospital factors alone. After adjustment, older age (Adjusted Odds Ratio [AOR] 1.02/year, 95% Confidence Interval [CI] 1.01-1.02) and public insurance (Medicare AOR 1.31, CI 1.21-1.43 and Medicaid AOR 1.43, CI 1.31-1.57; reference: Private Insurance) were associated with nonoperative management at LOH. These were similar at nLOH. At LOH, SNH status (AOR 1.17, CI 1.07-1.28) and small institution size (AOR 1.20, CI 1.09-1.34) were associated with increased odds of nonoperative management. CONCLUSION We noted a significant variability in the interhospital variation of the nonoperative management of acute cholecystitis. Nevertheless, comparable clinical and socioeconomic factors contribute to nonoperative management at both LOH and non-LOH. Directed strategies to address persistent non-clinical disparities are necessary to minimize deviation from standard protocol and ensure equitable care.
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Affiliation(s)
- Konmal Ali
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Nikhil L. Chervu
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Sara Sakowitz
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | | | - Peyman Benharash
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Jessica A. Keeley
- Division of Trauma and Critical Care, Department of Surgery, Harbor-UCLA Medical Center, Los Angeles, CA, United States of America
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Wood C, Chen X, Schpero W, Chatterjee P. Acquisitions of safety-net hospitals from 2016-2021: a case series. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae056. [PMID: 38915810 PMCID: PMC11195576 DOI: 10.1093/haschl/qxae056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/26/2024] [Accepted: 05/21/2024] [Indexed: 06/26/2024]
Abstract
Safety-net hospitals have recently become targets of acquisition by health systems with the stated purpose of improving their financial solvency and preserving access to safety-net services. Whether acquisition achieves these goals is unknown. In this descriptive case series, we sought to determine the factors that contribute to safety-net hospital acquisition, and identify whether safety-net services are preserved after acquisition. We examined 22 acquisitions of safety-net hospitals from 2016 to 2021 and described characteristics of the acquired safety-net hospitals, their acquiring systems, and the operational fate of acquired hospitals. Relative to other hospitals in the same Hospital Referral Region in the year prior to acquisition, acquired safety-net hospitals tended to be smaller and have lower occupancy rates. Acquiring systems were geographically concentrated, with only 6 of 20 systems operating in more than 1 state. Safety-net hospitals frequently offered typical safety-net services prior to acquisition. However, after acquisition, 2 of the 22 acquired safety-net hospitals lost safety-net services, 3 hospitals ceased inpatient services, and 1 hospital closed entirely. These findings suggest that acquisition of safety-net hospitals may be associated with trade-offs related to the provision of safety-net services for the communities that stand to benefit from them most.
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Affiliation(s)
- Christian Wood
- Department of Medicine, Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Xinwei Chen
- Department of Medicine, Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - William Schpero
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, NY 10075, United States
- Center for Health Equity, Cornell University, New York, NY 10075, United States
| | - Paula Chatterjee
- Department of Medicine, Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, United States
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Law AC, Bosch NA, Song Y, Tale A, Lasser KE, Walkey AJ. In-Hospital vs 30-Day Sepsis Mortality at US Safety-Net and Non-Safety-Net Hospitals. JAMA Netw Open 2024; 7:e2412873. [PMID: 38819826 PMCID: PMC11143462 DOI: 10.1001/jamanetworkopen.2024.12873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/11/2024] [Indexed: 06/01/2024] Open
Abstract
Importance In-hospital mortality of patients with sepsis is frequently measured for benchmarking, both by researchers and policymakers. Prior studies have reported higher in-hospital mortality among patients with sepsis at safety-net hospitals compared with non-safety-net hospitals; however, in critically ill patients, in-hospital mortality rates are known to be associated with hospital discharge practices, which may differ between safety-net hospitals and non-safety-net hospitals. Objective To assess how admission to safety-net hospitals is associated with 2 metrics of short-term mortality (in-hospital mortality and 30-day mortality) and discharge practices among patients with sepsis. Design, Setting, and Participants Retrospective, national cohort study of Medicare fee-for-service beneficiaries aged 66 years and older, admitted with sepsis to an intensive care unit from January 2011 to December 2019 based on information from the Medicare Provider Analysis and Review File. Data were analyzed from October 2022 to September 2023. Exposure Admission to a safety-net hospital (hospitals with a Medicare disproportionate share index in the top quartile per US region). Main Outcomes and Measures Coprimary outcomes: in-hospital mortality and 30-day mortality. Secondary outcomes: (1) in-hospital do-not-resuscitate orders, (2) in-hospital palliative care delivery, (3) discharge to a postacute facility (skilled nursing facility, inpatient rehabilitation facility, or long-term acute care hospital), and (4) discharge to hospice. Results Between 2011 and 2019, 2 551 743 patients with sepsis (mean [SD] age, 78.8 [8.2] years; 1 324 109 [51.9%] female; 262 496 [10.3%] Black, 2 137 493 [83.8%] White, and 151 754 [5.9%] other) were admitted to 666 safety-net hospitals and 1924 non-safety-net hospitals. Admission to safety-net hospitals was associated with higher in-hospital mortality (odds ratio [OR], 1.09; 95% CI, 1.06-1.13) but not 30-day mortality (OR, 1.01; 95% CI, 0.99-1.04). Admission to safety-net hospitals was associated with lower do-not-resuscitate rates (OR, 0.86; 95% CI, 0.81-0.91), palliative care delivery rates (OR, 0.66; 95% CI, 0.60-0.73), and hospice discharge (OR, 0.82; 95% CI, 0.78-0.87) but not with discharge to postacute facilities (OR, 0.98; 95% CI, 0.95-1.01). Conclusions and Relevance In this cohort study, among patients with sepsis, admission to safety-net hospitals was associated with higher in-hospital mortality but not with 30-day mortality. Differences in in-hospital mortality may partially be explained by greater use of hospice at non-safety-net hospitals, which shifts attribution of death from the index hospitalization to hospice. Future investigations and publicly reported quality measures should consider time-delimited rather than hospital-delimited measures of short-term mortality to avoid undue penalty to safety-net hospitals with similar short-term mortality.
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Affiliation(s)
- Anica C. Law
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nicholas A. Bosch
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Yang Song
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Archana Tale
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Karen E. Lasser
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Allan J. Walkey
- Division of Health Systems Science, Department of Medicine, University of Massachusetts Chan Medical School, Worcester
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Zhilkova A, Alsabahi L, Olson D, Maru D, Tsao TY, Morse ME. Hospital segregation, critical care strain, and inpatient mortality during the COVID-19 pandemic in New York City. PLoS One 2024; 19:e0301481. [PMID: 38603670 PMCID: PMC11008816 DOI: 10.1371/journal.pone.0301481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/16/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Hospital segregation by race, ethnicity, and health insurance coverage is prevalent, with some hospitals providing a disproportionate share of undercompensated care. We assessed whether New York City (NYC) hospitals serving a higher proportion of Medicaid and uninsured patients pre-pandemic experienced greater critical care strain during the first wave of the COVID-19 pandemic, and whether this greater strain was associated with higher rates of in-hospital mortality. METHODS In a retrospective analysis of all-payer NYC hospital discharge data, we examined changes in admissions, stratified by use of intensive care unit (ICU), from the baseline period in early 2020 to the first COVID-19 wave across hospital quartiles (265,329 admissions), and crude and risk-adjusted inpatient mortality rates, also stratified by ICU use, in the first COVID wave across hospital quartiles (23,032 inpatient deaths), based on the proportion of Medicaid or uninsured admissions from 2017-2019 (quartile 1 lowest to 4 highest). Logistic regressions were used to assess the cross-sectional association between ICU strain, defined as ICU volume in excess of the baseline average, and patient-level mortality. RESULTS ICU admissions in the first COVID-19 wave were 84%, 97%, 108%, and 123% of the baseline levels by hospital quartile 1-4, respectively. The risk-adjusted mortality rates for ICU admissions were 36.4 (CI = 34.7,38.2), 43.6 (CI = 41.5,45.8), 45.9 (CI = 43.8,48.1), and 45.7 (CI = 43.6,48.0) per 100 admissions, and those for non-ICU admissions were 8.6 (CI = 8.3,9.0), 10.9 (CI = 10.6,11.3), 12.6 (CI = 12.1,13.0), and 12.1 (CI = 11.6,12.7) per 100 admissions by hospital quartile 1-4, respectively. Compared with the reference group of 100% or less of the baseline weekly average, ICU admissions on a day for which the ICU volume was 101-150%, 151-200%, and > 200% of the baseline weekly average had odds ratios of 1.17 (95% CI = 1.10, 1.26), 2.63 (95% CI = 2.31, 3.00), and 3.26 (95% CI = 2.82, 3.78) for inpatient mortality, and non-ICU admissions on a day for which the ICU volume was 101-150%, 151-200%, and > 200% of the baseline weekly average had odds ratios of 1.28 (95% CI = 1.22, 1.34), 2.60 (95% CI = 2.40, 2.82), and 3.44 (95% CI = 3.11, 3.63) for inpatient mortality. CONCLUSIONS Our findings are consistent with hospital segregation as a potential driver of COVID-related mortality inequities and highlight the need to desegregate health care to address structural racism, advance health equity, and improve pandemic resiliency.
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Affiliation(s)
- Anna Zhilkova
- Center for Health Equity and Community Wellness at the New York City Department of Health and Mental Hygiene, Long Island City, NY, United States of America
| | - Laila Alsabahi
- Center for Health Equity and Community Wellness at the New York City Department of Health and Mental Hygiene, Long Island City, NY, United States of America
| | - Donald Olson
- Center for Health Equity and Community Wellness at the New York City Department of Health and Mental Hygiene, Long Island City, NY, United States of America
| | - Duncan Maru
- Center for Health Equity and Community Wellness at the New York City Department of Health and Mental Hygiene, Long Island City, NY, United States of America
| | - Tsu-Yu Tsao
- Center for Health Equity and Community Wellness at the New York City Department of Health and Mental Hygiene, Long Island City, NY, United States of America
| | - Michelle E. Morse
- Center for Health Equity and Community Wellness at the New York City Department of Health and Mental Hygiene, Long Island City, NY, United States of America
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Carroll NW, Shih SF, Karim SA, Lee SYD. Hospital Finances During the First Two Years of the COVID-19 Pandemic: Evidence From Washington State Hospitals. Adv Health Care Manag 2024; 22:143-160. [PMID: 38262014 DOI: 10.1108/s1474-823120240000022007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
The COVID-19 pandemic created a broad array of challenges for hospitals. These challenges included restrictions on admissions and procedures, patient surges, rising costs of labor and supplies, and a disparate impact on already disadvantaged populations. Many of these intersecting challenges put pressure on hospitals' finances. There was concern that financial pressure would be particularly acute for hospitals serving vulnerable populations, including safety-net (SN) hospitals and critical access hospitals (CAHs). Using data from hospitals in Washington State, we examined changes in operating margins for SN hospitals, CAHs, and other acute care hospitals in 2020 and 2021. We found that the operating margins for all three categories of hospitals fell from 2019 to 2020, with SNs and CAHs sustaining the largest declines. During 2021, operating margins improved for all three hospital categories but SN operating margins still remained negative. Both changes in revenue and changes in expenses contributed to observed changes in operating margins. Our study is one of the first to describe how the financial effects of COVID-19 differed for SNs, CAHs, and other acute care hospitals over the first two years of the pandemic. Our results highlight the continuing financial vulnerability of SNs and demonstrate how the factors that contribute to profitability can shift over time.
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Alsan M, Durvasula M, Gupta H, Schwartzstein J, Williams H. REPRESENTATION AND EXTRAPOLATION: EVIDENCE FROM CLINICAL TRIALS . THE QUARTERLY JOURNAL OF ECONOMICS 2024; 139:575-635. [PMID: 38859982 PMCID: PMC11164133 DOI: 10.1093/qje/qjad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
This article examines the consequences and causes of low enrollment of Black patients in clinical trials. We develop a simple model of similarity-based extrapolation that predicts that evidence is more relevant for decision-making by physicians and patients when it is more representative of the group being treated. This generates the key result that the perceived benefit of a medicine for a group depends not only on the average benefit from a trial but also on the share of patients from that group who were enrolled in the trial. In survey experiments, we find that physicians who care for Black patients are more willing to prescribe drugs tested in representative samples, an effect substantial enough to close observed gaps in the prescribing rates of new medicines. Black patients update more on drug efficacy when the sample that the drug is tested on is more representative, reducing Black-white patient gaps in beliefs about whether the drug will work as described. Despite these benefits of representative data, our framework and evidence suggest that those who have benefited more from past medical breakthroughs are less costly to enroll in the present, leading to persistence in who is represented in the evidence base.
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Affiliation(s)
- Marcella Alsan
- Harvard Kennedy School and National Bureau of Economic Research, United States
| | | | | | | | - Heidi Williams
- Stanford University and National Bureau of Economic Research, United States
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10
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Reid A, Karsten J, Barker K, Zervas M, Gissen A, Palazzo M. A Novel Role for Physical Therapists in Infection Prevention and Control in Response to the COVID-19 Pandemic: An Administrative Case Report. Phys Ther 2024; 104:pzad144. [PMID: 37843835 DOI: 10.1093/ptj/pzad144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 07/14/2023] [Accepted: 10/13/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVE The purpose of this case report is to describe the development, implementation, and sustained use of a Rehabilitation Infection Prevention and Control Team (RIPCT) comprised of physical therapists in response to the COVID-19 pandemic. It also highlights how physical therapists are equipped to serve not only in typical clinical positions but also in nontraditional roles in healthcare. METHODS The RIPCT served as an extension of the infection prevention and control (IPC) department. The team engaged in self-directed learning and worked alongside a physician mentor to acquire the knowledge and visibility needed to identify, triage, and address pandemic-related questions. Through rounding on units, on-site environmental assessments, and electronic communication, the RIPCT aided in navigating uncertainty, solving problems, and implementing changes for staff and patient safety. RESULTS The RIPCT addressed safety concerns of 532 rehabilitation professionals, developed rehabilitation IPC policy, facilitated the reopening of 11 ambulatory sites, and created a new pathway to address future rehabilitation IPC needs. A survey of rehabilitation professionals indicated perceived effectiveness of physical therapists filling this role. CONCLUSION The RIPCT successfully provided clear and consistent education as well as safe practice recommendations to staff and patients across a variety of disciplines and settings. The team quickly incorporated new knowledge and collaborated effectively in a nontraditional role within the healthcare system. The use of a semi-formal learning model with staff level clinicians as champions facilitated translation of IPC-related knowledge in a time of uncertainty throughout the healthcare community. IMPACT The educational background, professional values, and communication skills of physical therapists allowed for successful integration into the IPC department to ensure staff and patient safety. Healthcare systems should consider utilization of physical therapists in nontraditional multidisciplinary clinical roles.
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Affiliation(s)
- Abigail Reid
- Department of Physical Therapy, Rusk Rehabilitation, NYU Langone Health, New York, New York, USA
| | - Julia Karsten
- Department of Physical Therapy, Rusk Rehabilitation, NYU Langone Health, New York, New York, USA
| | - Kristin Barker
- Department of Physical Therapy, Rusk Rehabilitation, NYU Langone Health, New York, New York, USA
| | - Michael Zervas
- Department of Physical Therapy, Rusk Rehabilitation, NYU Langone Health, New York, New York, USA
| | - Amy Gissen
- Department of Physical Therapy, Rusk Rehabilitation, NYU Langone Health, New York, New York, USA
| | - Mia Palazzo
- Department of Physical Therapy, Rusk Rehabilitation, NYU Langone Health, New York, New York, USA
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11
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Secemsky EA, Kirksey L, Quiroga E, King CM, Martinson M, Hasegawa JT, West NEJ, Wadhera RK. Impact of Intensity of Vascular Care Preceding Major Amputation Among Patients With Chronic Limb-Threatening Ischemia. Circ Cardiovasc Interv 2024; 17:e012798. [PMID: 38152880 DOI: 10.1161/circinterventions.122.012798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 09/22/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Lower-limb amputation rates in patients with chronic limb-threatening ischemia vary across the United States, with marked disparities in amputation rates by gender, race, and income status. We evaluated the association of patient, hospital, and geographic characteristics with the intensity of vascular care received the year before a major lower-limb amputation and how intensity of care associates with outcomes after amputation. METHODS Using Medicare claims data (2016-2019), beneficiaries diagnosed with chronic limb-threatening ischemia who underwent a major lower-limb amputation were identified. We examined patient, hospital, and geographic characteristics associated with the intensity of vascular care received the year before amputation. Secondary objectives evaluated all-cause mortality and adverse events following amputation. RESULTS Of 33 036 total Medicare beneficiaries undergoing major amputation, 7885 (23.9%) were due to chronic limb-threatening ischemia; of these, 4988 (63.3%) received low-intensity and 2897 (36.7%) received high-intensity vascular care. Mean age, 76.6 years; women, 38.9%; Black adults, 24.5%; and of low income, 35.2%. After multivariable adjustment, those of low income (odds ratio, 0.65 [95% CI, 0.58-0.72]; P<0.001), and to a lesser extent, men (odds ratio, 0.89 [95% CI, 0.81-0.98]; P=0.019), and those who received care at a safety-net hospital (odds ratio, 0.87 [95% CI, 0.78-0.97]; P=0.012) were most likely to receive low intensity of care before amputation. High-intensity care was associated with a lower risk of all-cause mortality 2 years following amputation (hazard ratio, 0.79 [95% CI, 0.74-0.85]; P<0.001). CONCLUSIONS Patients who were of low-income status, and to a lesser extent, men, or those cared for at safety-net hospitals were most likely to receive low-intensity vascular care. Low-intensity care was associated with worse long-term event-free survival. These data emphasize the continued disparities that exist in contemporary vascular practice.
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Affiliation(s)
- Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (E.A.S., R.K.W.)
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic, OH (L.K.)
| | - Elina Quiroga
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle (E.Q.)
| | - Claire M King
- Abbott Vascular, Santa Clara, CA (C.M.K., J.T.H., N.E.J.W.)
| | | | | | - Nick E J West
- Abbott Vascular, Santa Clara, CA (C.M.K., J.T.H., N.E.J.W.)
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (E.A.S., R.K.W.)
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12
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Wang MC, Bangaru S, Zhou K. Care for Vulnerable Populations with Chronic Liver Disease: A Safety-Net Perspective. Healthcare (Basel) 2023; 11:2725. [PMID: 37893800 PMCID: PMC10606794 DOI: 10.3390/healthcare11202725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Safety-net hospitals (SNHs) and facilities are the cornerstone of healthcare services for the medically underserved. The burden of chronic liver disease-including end-stage manifestations of cirrhosis and liver cancer-is high and rising among populations living in poverty who primarily seek and receive care in safety-net settings. For many reasons related to social determinants of health, these individuals often present with delayed diagnoses and disease presentations, resulting in higher liver-related mortality. With recent state-based policy changes such as Medicaid expansion that impact access to insurance and critical health services, an overview of the body of literature on SNH care for chronic liver disease is timely and informative for the liver disease community. In this narrative review, we discuss controversies in the definition of a SNH and summarize the known disparities in the cascade of the care and management of common liver-related conditions: (1) steatotic liver disease, (2) liver cancer, (3) chronic viral hepatitis, and (4) cirrhosis and liver transplantation. In addition, we review the specific impact of Medicaid expansion on safety-net systems and liver disease outcomes and highlight effective provider- and system-level interventions. Lastly, we address remaining gaps and challenges to optimizing care for vulnerable populations with chronic liver disease in safety-net settings.
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Affiliation(s)
- Mark C Wang
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Saroja Bangaru
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Los Angeles General Medical Center, Los Angeles, CA 90033, USA
| | - Kali Zhou
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Los Angeles General Medical Center, Los Angeles, CA 90033, USA
- Research Center for Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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McNeill E, Cronin C, Puro N, Franz B, Silver D, Chang J. Variance of US Hospital Characteristics by Safety-Net Definition. JAMA Netw Open 2023; 6:e2332392. [PMID: 37672276 PMCID: PMC10483314 DOI: 10.1001/jamanetworkopen.2023.32392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/26/2023] [Indexed: 09/07/2023] Open
Abstract
This cross-sectional study examines whether characteristics of hospitals differ across 5 frequently used safety-net hospital definitions using 2020 data.
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Affiliation(s)
- Elizabeth McNeill
- New York University School of Global Public Health, New York, New York
| | - Cory Cronin
- Ohio University, Athens, Ohio
- Appalachian Institute to Advance Health Equity Science (ADVANCE), Athens, Ohio
| | - Neeraj Puro
- Florida Atlantic University, Boca Raton, Florida
| | - Berkeley Franz
- Appalachian Institute to Advance Health Equity Science (ADVANCE), Athens, Ohio
- Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio
| | - Diana Silver
- New York University School of Global Public Health, New York, New York
| | - Ji Chang
- New York University School of Global Public Health, New York, New York
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14
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Chang JE, Franz B, Pagán JA, Lindenfeld Z, Cronin CE. Substance Use Disorder Program Availability in Safety-Net and Non-Safety-Net Hospitals in the US. JAMA Netw Open 2023; 6:e2331243. [PMID: 37639270 PMCID: PMC10463097 DOI: 10.1001/jamanetworkopen.2023.31243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/23/2023] [Indexed: 08/29/2023] Open
Abstract
Importance Safety-net hospitals (SNHs) are ideal sites to deliver addiction treatment to patients with substance use disorders (SUDs), but the availability of these services within SNHs nationwide remains unknown. Objective To examine differences in the delivery of different SUD programs in SNHs vs non-SNHs across the US and to determine whether these differences are increased in certain types of SNHs depending on ownership. Design, Setting, and Participants This cross-sectional analysis used data from the 2021 American Hospital Association Annual Survey of Hospitals to examine the associations of safety-net status and ownership with the availability of SUD services at acute care hospitals in the US. Data analysis was performed from January to March 2022. Main Outcomes and Measures This study used 2 survey questions from the American Hospital Association survey to determine the delivery of 5 hospital-based SUD services: screening, consultation, inpatient treatment services, outpatient treatment services, and medications for opioid use disorder (MOUD). Results A total of 2846 hospitals were included: 409 were SNHs and 2437 were non-SNHs. The lowest proportion of hospitals reported offering inpatient treatment services (791 hospitals [27%]), followed by MOUD (1055 hospitals [37%]), and outpatient treatment services (1087 hospitals [38%]). The majority of hospitals reported offering consultation (1704 hospitals [60%]) and screening (2240 hospitals [79%]). In multivariable models, SNHs were significantly less likely to offer SUD services across all 5 categories of services (screening odds ratio [OR], 0.62 [95% CI, 0.48-0.76]; consultation OR, 0.62 [95% CI, 0.47-0.83]; inpatient services OR, 0.73 [95% CI, 0.55-0.97]; outpatient services OR, 0.76 [95% CI, 0.59-0.99]; MOUD OR, 0.6 [95% CI, 0.46-0.78]). With the exception of MOUD, public or for-profit SNHs did not differ significantly from their non-SNH counterparts. However, nonprofit SNHs were significantly less likely to offer all 5 SUD services compared with their non-SNH counterparts (screening OR, 0.52 [95% CI, 0.41-0.66]; consultation OR, 0.56 [95% CI, 0.44-0.73]; inpatient services OR, 0.45 [95% CI, 0.33-0.61]; outpatient services OR, 0.58 [95% CI, 0.44-0.76]; MOUD OR, 0.61 [95% CI, 0.46-0.79]). Conclusions and Relevance In this cross-sectional study of SNHs and non-SNHs, SNHs had significantly lower odds of offering the full range of SUD services. These findings add to a growing body of research suggesting that SNHs may face additional barriers to offering SUD programs. Further research is needed to understand these barriers and to identify strategies that support the adoption of evidence-based SUD programs in SNH settings.
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Affiliation(s)
- Ji E. Chang
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, New York
| | - Berkeley Franz
- Heritage College of Osteopathic Medicine, Ohio University, Athens
| | - José A. Pagán
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, New York
| | - Zoe Lindenfeld
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, New York
| | - Cory E. Cronin
- College of Health Sciences and Professions, Ohio University, Athens
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15
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Miller ER, Hudak ML. Medicaid and newborn care: challenges and opportunities. J Perinatol 2023; 43:1072-1078. [PMID: 37438483 DOI: 10.1038/s41372-023-01714-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 05/30/2023] [Accepted: 06/21/2023] [Indexed: 07/14/2023]
Abstract
Since its creation in 1965, Medicaid has operated as a federal-state partnership that provides a robust set of medical benefits to low-income families, including pregnant people and infants. In many ways, Medicaid has met its initial promise. However, medical benefits, provider payments, and key administrative procedures regarding eligibility, enrollment, and access to care vary substantially among state Medicaid programs. These variations have created profound inequities across states in the care of parents and children, particularly during pregnancy and in the postpartum and neonatal periods. Here we review select aspects of the Medicaid program pertinent to newborns and infants that contribute to eligibility and enrollment gaps, variations in benefits coverage and payment rates, and racial disparities in both access to healthcare and infant health outcomes. We outline a number of structural reforms of the Medicaid program that can improve newborn and infant access to care and outcomes and redress existing inequities.
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Affiliation(s)
- Emily R Miller
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA.
| | - Mark L Hudak
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
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16
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Phillips KA, Marshall DA, Adler L, Figueroa J, Haeder SF, Hamad R, Hernandez I, Moucheraud C, Nikpay S. Ten health policy challenges for the next 10 years. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad010. [PMID: 38756834 PMCID: PMC10986244 DOI: 10.1093/haschl/qxad010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/14/2023] [Indexed: 05/18/2024]
Abstract
Health policies and associated research initiatives are constantly evolving and changing. In recent years, there has been a dizzying increase in research on emerging topics such as the implications of changing public and private health payment models, the global impact of pandemics, novel initiatives to tackle the persistence of health inequities, broad efforts to reduce the impact of climate change, the emergence of novel technologies such as whole-genome sequencing and artificial intelligence, and the increase in consumer-directed care. This evolution demands future-thinking research to meet the needs of policymakers in translating science into policy. In this paper, the Health Affairs Scholar editorial team describes "ten health policy challenges for the next 10 years." Each of the ten assertions describes the challenges and steps that can be taken to address those challenges. We focus on issues that are traditionally studied by health services researchers such as cost, access, and quality, but then examine emerging and intersectional topics: equity, income, and justice; technology, pharmaceuticals, markets, and innovation; population health; and global health.
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Affiliation(s)
- Kathryn A Phillips
- UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), University of California, San Francisco, San Francisco, CA 94143, United States
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA 94143, United States
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA 94158, United States
| | - Deborah A Marshall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta T2N 4Z6, Canada
- Alberta Children's Hospital Research Institute, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta T2N 4Z6, Canada
| | - Loren Adler
- USC-Brookings Schaeffer Initiative for Health Policy, Brookings Institution, Washington, DC 90089, United States
| | - Jose Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States
- Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Simon F Haeder
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX 77843, United States
| | - Rita Hamad
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA 94158, United States
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA 94110, United States
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States
| | - Inmaculada Hernandez
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, San Diego, CA 92093, United States
| | - Corrina Moucheraud
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA 90095, United States
- UCLA Center for Health Policy Research, University of California, Los Angeles, Los Angeles, CA 90024, United States
| | - Sayeh Nikpay
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN 55455, United States
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Simpson KR, Spetz J, Gay CL, Fletcher J, Landstrom GL, Lyndon A. Hospital characteristics associated with nurse staffing during labor and birth: Inequities for the most vulnerable maternity patients. Nurs Outlook 2023; 71:101960. [PMID: 37004352 PMCID: PMC10913105 DOI: 10.1016/j.outlook.2023.101960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 01/06/2023] [Accepted: 02/22/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Evidence is limited on nurse staffing in maternity units. PURPOSE To estimate the relationship between hospital characteristics and adherence with Association of Women's Health, Obstetric and Neonatal Nurses nurse staffing guidelines. METHODS We enrolled 3,471 registered nurses in a cross-sectional survey and obtained hospital characteristics from the 2018 American Hospital Association Annual Survey. We used mixed-effects linear regression models to estimate associations between hospital characteristics and staffing guideline adherence. FINDINGS Overall, nurses reported strong adherence to AWHONN staffing guidelines (rated frequently or always met by ≥80% of respondents) in their hospitals. Higher birth volume, having a neonatal intensive care unit, teaching status, and higher percentage of births paid by Medicaid were all associated with lower mean guideline adherence scores. DISCUSSION AND CONCLUSIONS Important gaps in staffing were reported more frequently at hospitals serving patients more likely to have medical or obstetric complications, leaving the most vulnerable patients at risk.
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Affiliation(s)
| | - Joanne Spetz
- Phillip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA
| | - Caryl L Gay
- Department of Family Health Care Nursing, University of California San Francisco School of Nursing, San Francisco, CA
| | - Jason Fletcher
- Rory Meyers College of Nursing, New York University, New York, NY
| | | | - Audrey Lyndon
- Department of Family Health Care Nursing, University of California San Francisco School of Nursing, San Francisco, CA; Rory Meyers College of Nursing, New York University, New York, NY.
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18
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Baker NC. Safety Net Hospitals and Cardiovascular Outcomes: Consider the Source? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 49:13-14. [PMID: 36707374 DOI: 10.1016/j.carrev.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Affiliation(s)
- Nevin C Baker
- Department of Interventional Cardiology, Excela Health, Greensburg, PA, United States of America.
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Bashar H, Bharadwaj A, Matetić A, Ullah W, Beasley DL, Bullock-Palmer RP, Curzen N, Mamas MA. Invasive Management and In-Hospital Outcomes of Myocardial Infarction Patients in United States Safety-Net Hospitals. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 49:7-12. [PMID: 36411236 DOI: 10.1016/j.carrev.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/19/2022]
Abstract
AIM Safety-net hospitals (SNHs) look after a higher proportion of uninsured patients and are often located in deprived areas. This study aimed to determine whether there are differences in the clinical characteristics, treatments and outcomes of patients presenting with acute myocardial infarction (AMI) in SNHs versus non-SNHs (N-SNHs). METHODS All hospitalizations with a principal diagnosis of AMI in the United States' National Inpatient Sample between 2016 and 2019 were stratified by safety-net hospital status. Multivariable logistic regression with adjusted odds ratios (aOR) and 95 % confidence intervals (95 % CI) was conducted to investigate invasive management and clinical outcomes. RESULTS A total of 2,544,009 weighted discharge records were analyzed, including 601,719 records from SNHs (23.7 %). Compared with N-SNHs, SNH AMI patients were younger (median 66 years vs. 67 years, p < 0.001), and had a higher proportion in the lowest quartile of median household income (37.3 % vs. 28.5 %, p < 0.001). Patients from SNHs were less likely to receive coronary angiography (aOR 0.92, 95 % CI 0.91-0.93, p < 0.001), percutaneous coronary intervention (aOR 0.94, 95 % CI 0.93-0.95, p < 0.001), and coronary artery bypass grafting (aOR 0.93, 95 % CI 0.92-0.94, p < 0.001). In addition, they had increased all-cause mortality (aOR 1.11, 95 % CI 1.09-1.12, p < 0.001), major adverse cardiovascular/cerebrovascular events (composite of mortality, stroke and reinfarction) (aOR 1.11, 95 % CI 1.09-1.12, p < 0.001), and stroke (aOR 1.11, 95 % CI 1.08-1.14, p < 0.001), while there was no difference in major bleeding (aOR 1.02, 95 % CI 1.00-1.04, p = 0.107). CONCLUSION Among AMI patients, treatment in SNHs was associated with lower utilization of coronary angiography and revascularization and worse clinical outcomes.
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Affiliation(s)
- Hussein Bashar
- Faculty of Medicine, University of Southampton, United Kingdom; Coronary Research Group, University Hospital Southampton NHS Foundation Trust, United Kingdom; Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, United Kingdom
| | - Aditya Bharadwaj
- Division of Cardiology, Loma Linda University, California, United States
| | - Andrija Matetić
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, United Kingdom; Department of Cardiology, University Hospital of Split, Split, Croatia
| | - Waqas Ullah
- Thomas Jefferson University, Philadelphia, PA, United States
| | - Dorian L Beasley
- Adult General and Interventional Cardiology, Community Health Network, Indianapolis, IN, United States
| | - Renee P Bullock-Palmer
- Department of Cardiology, Deborah Heart and Lung Center, Browns Mills, NJ, United States
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, United Kingdom; Coronary Research Group, University Hospital Southampton NHS Foundation Trust, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, United Kingdom.
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Mota L, Marcaccio CL, Patel PB, Soden PA, Moreira CC, Stangenberg L, Hughes K, Schermerhorn ML. The impact of neighborhood social disadvantage on abdominal aortic aneurysm severity and management. J Vasc Surg 2023; 77:1077-1086.e2. [PMID: 36347436 PMCID: PMC10038823 DOI: 10.1016/j.jvs.2022.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/22/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recent studies have highlighted socioeconomic disparities in the severity and management of abdominal aortic aneurysm (AAA) disease. However, these studies focus on individual measures of social disadvantage such as income and insurance status. The area deprivation index (ADI), a validated measure of neighborhood deprivation, provides a more comprehensive assessment of social disadvantage. Therefore, we examined the impact of ADI on AAA severity and its management. METHODS We identified all patients who underwent endovascular or open repair of an AAA in the Vascular Quality Initiative registry between 2003 and 2020. An ADI score of 1 to 100 was assigned to each patient based on their residential zip code, with higher ADI scores corresponding with increasing deprivation. Patients were categorized by ADI quintiles. Outcomes of interest included rates of ruptured AAA (rAAA) repair versus an intact AAA repair and rates of endovascular repair (EVAR) versus the open approach. Logistic regression was used to evaluate for an independent association between ADI quintile and these outcomes. RESULTS Among 55,931 patients who underwent AAA repair, 6649 (12%) were in the lowest ADI quintile, 11,692 (21%) in the second, 15,958 (29%) in the third, 15,035 (27%) in the fourth, and 6597 (12%) in the highest ADI quintile. Patients in the two highest ADI quintiles had a higher proportion of rAAA repair (vs intact repair) compared with those in the lowest ADI quintile (8.8% and 9.1% vs 6.2%; P < .001). They were also less likely to undergo EVAR (vs open approach) when compared with the lowest ADI quintile (81% and 81% vs 88%; P < .001). There was an overall trend toward increasing rAAA and decreasing EVAR rates with increasing ADI quintiles (P < .001). In adjusted analyses, when compared with patients in the lowest ADI quintile, patients in the highest ADI quintile had higher odds of rAAA repair (odds ratio, 1.4; 95% confidence interval, 1.2-1.8; P < .001) and lower odds of undergoing EVAR (odds ratio, 0.54; 95% confidence interval, 0.45-0.65; P < .001). CONCLUSIONS Among patients who underwent AAA repair in the Vascular Quality Initiative, those with higher neighborhood deprivation had significantly higher rates of rAAA repair (vs intact repair) and lower rates of EVAR (vs open approach). Further work is needed to better understand neighborhood factors that are contributing to these disparities to identify community-level targets for improvement.
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Affiliation(s)
- Lucas Mota
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Peter A Soden
- Division of Vascular Surgery, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Carla C Moreira
- Division of Vascular Surgery, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Lars Stangenberg
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kakra Hughes
- Division of Vascular Surgery, Department of Surgery, Howard University College of Medicine, Washington, DC
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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Oseran AS, Wadhera RK, Orav EJ, Figueroa JF. Effect of Medicare Advantage on Hospital Readmission and Mortality Rankings. Ann Intern Med 2023; 176:480-488. [PMID: 36972544 DOI: 10.7326/m22-3165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Medicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including Medicare Advantage (MA) beneficiaries, who account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown. OBJECTIVE To determine if the inclusion of MA beneficiaries in readmission and mortality measures reclassifies hospital performance rankings compared with current measures. DESIGN Cross-sectional. SETTING Population-based. PARTICIPANTS Hospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program. MEASUREMENTS Using the 100% Medicare files for FFS and MA claims, the authors calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia on the basis of only FFS beneficiaries and then both FFS and MA beneficiaries. Hospitals were divided into quintiles of performance based on FFS beneficiaries only, and the proportion of hospitals that were reclassified to a different performance group with the inclusion of MA beneficiaries was calculated. RESULTS Of the hospitals in the top-performing quintile for readmissions and mortality based on FFS beneficiaries, between 21.6% and 30.2% were reclassified to a lower-performing quintile with the inclusion of MA beneficiaries. Similar proportions of hospitals were reclassified from the bottom performance quintile to a higher one across all measures and conditions. Hospitals with a higher proportion of MA beneficiaries were more likely to improve in performance rankings. LIMITATION Hospital performance measurement and risk adjustment differed slightly from those used by Medicare. CONCLUSION Approximately 1 in 4 top-performing hospitals is reclassified to a lower performance group when MA beneficiaries are included in the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance. PRIMARY FUNDING SOURCE Laura and John Arnold Foundation.
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Affiliation(s)
- Andrew S Oseran
- Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts (A.S.O.)
| | - Rishi K Wadhera
- Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.K.W.)
| | - E John Orav
- Harvard T.H. Chan School of Public Health and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (E.J.O., J.F.F.)
| | - Jose F Figueroa
- Harvard T.H. Chan School of Public Health and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (E.J.O., J.F.F.)
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22
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Pettit NR, Li X, Stewart L, Kline J. Worsened outcomes of newly diagnosed cancer in patients with recent emergency care visits: A retrospective cohort study of 3699 adults in a safety net health system. Cancer Med 2023; 12:4832-4841. [PMID: 36394210 PMCID: PMC9972123 DOI: 10.1002/cam4.5303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/11/2022] [Accepted: 09/16/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Many patients receive a suspected diagnosis of cancer through an emergency department (ED) visit. Time to treatment for a new diagnosis of cancer is directly associated with improved outcomes with little no describing the ED utilization prior to the diagnosis of cancer. We hypothesize that patients that have an ED visit in proximity to a diagnosis of cancer will have worse outcomes, including mortality. METHODS This study is a retrospective cohort study of all patients with cancer diagnosed at Eskenazi Health (Indiana) between 2016 and 2019. Individual health characteristics, ED utilization, cancer types, and mortality were studied. We compared those patients seen in the ED within 6 months prior to their diagnosis (cases) to patients not seen in the ED (controls). RESULTS A total of 3699 patients with cancer were included, with 1239 cases (33.50%). Patients of black race had higher frequencies in the cases vs. controls (46.57% vs. 40.68%). Lung cancer was the most frequently observed cancer among cases vs. controls (11.70% vs. 5.57%). For the cases, 232 patients were deceased (18.72%) compared with 247 patients among the controls (10.04%, p < 0.0001, OR 2.06 95% confidence interval [CI] 1.70-2.51). An ED visit in past 6 months (OR = 1.73, 95% CI 1.38-2.18) and Medicaid insurance type (versus commercial, OR = 4.16, 95% CI 2.45-7.07) were associated with of mortality. Female gender (OR = 0.76, 95% CI 0.67-0.88), tobacco use (OR = 1.62, 95% CI 138-1.90), and Medicaid insurance type (versus commercial, OR = 2.56, 95% CI 2.07-3.47) were associated with prior ED use. CONCLUSIONS Over one third of patients with cancer were seen in the ED within 6 months prior to their cancer diagnosis. Higher mortality rates were observed for those seen in the ED. Future studies are needed to investigate the association and impact that the ED has on eventual cancer diagnoses and outcomes.
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Affiliation(s)
- Nicholas R Pettit
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA.,Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Xin Li
- Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Lauren Stewart
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Jeffrey Kline
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA.,Department of Emergency Medicine, Wayne State University, Detroit, Michigan, USA
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23
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Impact of Hospital Safety-Net Burden on Outcomes of In-Hospital Cardiac Arrest in the United States. Crit Care Explor 2023; 5:e0838. [PMID: 36699243 PMCID: PMC9831170 DOI: 10.1097/cce.0000000000000838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
High safety-net burden hospitals (HBHs) treating large numbers of uninsured or Medicaid-insured patients have generally been linked to worse clinical outcomes. However, limited data exist on the impact of the hospitals' safety-net burden on in-hospital cardiac arrest (IHCA) outcomes in the United States. OBJECTIVES To compare the differences in survival to discharge, routine discharge home, and healthcare resource utilization between patients at HBH with those treated at low safety-net burden hospital (LBH). DESIGN SETTING AND PARTICIPANTS Retrospective cohort study across hospitals in the United States: Hospitalized patients greater than or equal to 18 years that underwent cardiopulmonary resuscitation (CPR) between 2008 and 2018 identified from the Nationwide Inpatient Database. Data analysis was conducted in January 2022. EXPOSURE IHCA. MAIN OUTCOMES AND MEASURES The primary outcome is survival to hospital discharge. Other outcomes are routine discharge home among survivors, length of hospital stay, and total hospitalization cost. RESULTS From 2008 to 2018, an estimated 555,016 patients were hospitalized with IHCA, of which 19.2% occurred at LBH and 55.2% at HBH. Compared with LBH, patients at HBH were younger (62 ± 20 yr vs 67 ± 17 yr) and predominantly in the lowest median household income (< 25th percentile). In multivariate analysis, HBH was associated with lower chances of survival to hospital discharge (adjusted odds ratio [aOR], 0.88; 95% CI, 0.85-0.96) and lower odds of routine discharge (aOR, 0.6; 95% CI, 0.47-0.75), compared with LBH. In addition, IHCA patients at publicly owned hospitals and those with medium and large hospital bed size were less likely to survive to hospital discharge, while patients with median household income greater than 25th percentile had better odds of hospital survival. CONCLUSIONS AND RELEVANCE Our study suggests that patients who experience IHCA at HBH may have lower rates and odds of in-hospital survival and are less likely to be routinely discharged home after CPR. Median household income and hospital-level characteristics appear to contribute to survival.
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24
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Ciomperlik H, Mohr C, Dhanani N, Hannon C, Saucedo B, Shah P, Olavarria OA, Liang MK, Holihan JL. Safety and Feasibility of Performing Antireflux Procedures at a Safety Net Hospital. J Surg Res 2023; 281:307-313. [PMID: 36228341 DOI: 10.1016/j.jss.2022.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 07/26/2022] [Accepted: 08/19/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION One-half of Americans have limited access to health care; these patients often receive care through safety net hospitals, which are associated with worse medical outcomes. This study aims to compare the outcomes of patients who received foregut surgery at a safety net hospital to those at a private or university hospital. We hypothesized that patients treated at the safety net hospital will have a greater rate of radiographic recurrence and reoperations. METHODS A retrospective study was conducted on patients who underwent hiatal hernia repair or fundoplication for gastroesophageal reflux disease at an affiliated safety net, private, or university hospital from June 2015 to May 2020. The primary outcome was radiographic recurrence. The secondary outcomes included reoperation and symptom recurrence. Analysis was performed using analysis of variance, chi-square, and logistic regression. RESULTS A total of 499 patients were identified: 157 at a safety net hospital, 233 at a private hospital, and 119 at a university hospital. The median (interquartile range) follow-up was 16 (13) mo. The safety net hospital treated more Hispanics, females, and patients with comorbidities. Large hiatal hernias were more common at the safety net and private hospitals. Robotic surgery was more frequently at the university hospital. There was no difference in radiographic recurrence (13.4% versus 19.7% versus 17.6%; P = 0.269), reoperation (3.8% versus 7.2% versus 6.7%; P = 0.389), or postoperative dysphagia (15.3% versus 12.6% versus 15.1%; P = 0.696). On logistic regression, there were no differences in outcomes among institutions. CONCLUSIONS This study suggests that despite the challenges faced at safety net hospitals, it could be feasible to safely perform minimally invasive foregut surgery with similar outcomes to private and university hospitals.
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Affiliation(s)
- Hailie Ciomperlik
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas.
| | - Cassandra Mohr
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas
| | - Naila Dhanani
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas
| | - Craig Hannon
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas
| | - Brenda Saucedo
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas
| | - Puja Shah
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas
| | - Oscar A Olavarria
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas
| | - Mike K Liang
- Department of Surgery, HCA Healthcare Kingwood, University of Houston, Kingwood, Texas
| | - Julie L Holihan
- Department of Surgery, Lyndon B. Johnson General Hospital, McGovern Medical School at UTHealth, Houston, Texas
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25
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Tilmon S, Aronsohn A, Boodram B, Canary L, Goel S, Hamlish T, Kemble S, Lauderdale DS, Layden J, Lee K, Millman AJ, Nelson N, Ritger K, Rodriguez I, Shurupova N, Wolf J, Johnson D. HepCCATT: a multilevel intervention for hepatitis C among vulnerable populations in Chicago. J Public Health (Oxf) 2022; 44:891-899. [PMID: 34156077 PMCID: PMC8692481 DOI: 10.1093/pubmed/fdab190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/07/2021] [Accepted: 05/20/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Hepatitis C infection could be eliminated. Underdiagnosis and lack of treatment are the barriers to cure, especially for vulnerable populations (i.e. unable to pay for health care). METHODS A multilevel intervention from September 2014 to September 2019 focused on the providers and organizations in 'the safety net' (providing health care to populations unable to pay), including: (i) public education, (ii) training for primary care providers (PCPs) and case managers, (iii) case management for high-risk populations, (iv) policy advice and (v) a registry (Registry) for 13 health centers contributing data. The project tracked the number of PCPs trained and, among Registry sites, the number of people screened, engaged in care (i.e. clinical follow-up after diagnosis), treated and/or cured. RESULTS In Chicago, 215 prescribing PCPs and 56 other health professionals, 86% of whom work in the safety net, were trained to manage hepatitis C. Among Registry sites, there was a 137% increase in antibody screening and a 32% increase in current hepatitis C diagnoses. Engagement in care rose by 18%. CONCLUSIONS Hepatitis C Community Alliance to Test and Treat (HepCCATT) successfully targeted safety net providers and organizations with a comprehensive care approach. While there were challenges, HepCCATT observed increased hepatitis C screening, diagnosis and engagement in care in the Chicago community.
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Affiliation(s)
- Sandra Tilmon
- Academic Pediatrics, University of Chicago Medicine, Chicago, IL 60637, USA
| | - A Aronsohn
- Gastroenterology, University of Chicago Medicine, Chicago, IL 60637, USA
| | - B Boodram
- Department of Public Health, University of Illinois at Chicago, Chicago, IL 60607, USA
| | - L Canary
- CDC: Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, GA 30329, USA
| | - S Goel
- Division of General Internal Medicine and Geriatrics, Northwestern University (Medicine), Chicago, IL 60611 USA
| | - T Hamlish
- Cancer Center, University of Illinois at Chicago, Chicago, IL 60612 USA
| | - S Kemble
- Hawaii Department of Health, Honolulu, HI 96813, USA
| | - D S Lauderdale
- Public Health Sciences, University of Chicago Medicine, Chicago, IL 60637
| | - J Layden
- Illinois Department of Public Health, West Chicago, IL 60185, USA
| | - K Lee
- Academic Pediatrics, University of Chicago Medicine, Chicago, IL 60637, USA
| | - A J Millman
- CDC: Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, GA 30329, USA
| | - N Nelson
- CDC: Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, GA 30329, USA
| | - K Ritger
- Chicago Department of Public Health, Chicago, IL 60604, USA
| | - I Rodriguez
- Academic Pediatrics, University of Chicago Medicine, Chicago, IL 60637, USA
| | - N Shurupova
- Medical Research Analytics and Informatics Alliance (MRAIA), Chicago, IL 60606, USA
| | - J Wolf
- Caring Ambassadors Program, Oregon City, OR 97045, USA
| | - D Johnson
- Academic Pediatrics, University of Chicago Medicine, Chicago, IL 60637, USA
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Chatterjee P, Sinha S, Reszczynski O, Amin A, Schpero WL. Variation And Changes In The Targeting Of Medicaid Disproportionate Share Hospital Payments. Health Aff (Millwood) 2022; 41:1781-1789. [PMID: 36469825 DOI: 10.1377/hlthaff.2022.00153] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Little is known about how Medicaid disproportionate share hospital payments, which are intended to support hospitals that serve low-income patients, are allocated or whether allocation patterns have changed over time. We employed alternative definitions of targeting, or the degree to which allocations were made in a manner consistent with the statutory goals and intent of the program, to examine disproportionate share hospital payment allocations in forty-nine participating states. The most recent data indicate that 57.2 percent of acute care hospitals received disproportionate share hospital payments, totaling more than $14.5 billion, in 2015. The majority of payments went to hospitals with Medicaid shares above the state-specific median (89.1 percent), hospitals with uncompensated care shares above the state-specific median (60.6 percent), or hospitals deemed as disproportionate share per statutory definitions (64.6 percent). However, among all hospitals receiving these payments, up to 31.6 percent of payments were allocated to hospitals that did not meet a given definition, and 3.2 percent went to hospitals that met none of them. These findings suggest that although the majority of the payments were targeted to hospitals serving low-income patients, opportunities exist to better align allocation with statutory goals and intent or to revise applicable statute.
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Affiliation(s)
- Paula Chatterjee
- Paula Chatterjee , University of Pennsylvania, Philadelphia, Pennsylvania
| | - Soham Sinha
- Soham Sinha, University of Chicago, Chicago, Illinois
| | - Olivia Reszczynski
- Olivia Reszczynski, Medical University of South Carolina, Charleston, South Carolina
| | - Anita Amin
- Anita Amin, Cornell University, New York, New York
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27
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Nwana N, Chan W, Langabeer J, Kash B, Krause TM. Does hospital location matter? Association of neighborhood socioeconomic disadvantage with hospital quality in US metropolitan settings. Health Place 2022; 78:102911. [DOI: 10.1016/j.healthplace.2022.102911] [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: 04/08/2022] [Revised: 08/03/2022] [Accepted: 09/11/2022] [Indexed: 11/13/2022]
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Comparison of Premium Technology Utilization in Total Hip Arthroplasty Between Safety-net Hospitals and Non-safety-net Hospitals. J Am Acad Orthop Surg 2022; 30:e1402-e1410. [PMID: 35947828 DOI: 10.5435/jaaos-d-22-00376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 06/05/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The objective of our study was to investigate the association of safety-net hospital (SNH) status with the use of premium technologies in total hip arthroplasty (THA) using the American Academy of Orthopaedic Surgeons American Joint Replacement Registry. METHODS Premium technology was defined as having one or more of the following three characteristics: ceramic femoral head, dual mobility (DM) bearing, or surgery conducted with robotic assistance (RA). Patients of all ages were included and subdivided into ceramic femoral head, DM, and RA cohorts. SNH status (based on disproportionate share data), patient demographics, geographical region, hospital size, and teaching affiliation were assessed. Multivariate regression analysis was conducted to analyze any notable associations. RESULTS A total of 624,933 THAs between SNHs and non-SNHs were available for analysis. Based on the three different premium technology categories, there were 551,838 THAs for ceramic femoral head utilization analysis, 601,223 THAs for DM utilization analysis, and 199,250 THAs for RA utilization analysis. SNHs were associated with less use of DM and RA (odds ratio [OR] 0.53 P < 0.0001, 0.39 P < 0.0001, respectively). No difference was observed in ceramic femoral head utilization between SNHs and non-SNHs. Patient age was significantly associated with less utilization of all three premium THA technologies (ceramic: OR 0.43 P < 0.0001; DM: OR 0.93 P < 0.0001, RA: OR 0.89 P < 0.001). Teaching hospitals were significantly associated with increased utilization of premium THA technologies (ceramic: OR 1.23 P < 0.0001, DM: OR 1.62 P < 0.0001, RA: OR 5.33 P < 0.001). CONCLUSION Premium THA technologies are becoming increasingly used across the US healthcare system; however, that growth is not equal in hospitals with marginalized patient populations. The utilization of ceramic femoral heads is becoming increasingly common across healthcare systems suggesting that ceramic femoral heads may no longer be considered premium technology but rather standard THA care. LEVEL OF EVIDENCE Level III.
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29
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Handcox JE, Saucedo JM, Rose RA, Corley FG, Brady CI. Providing Orthopaedic Care to Vulnerably Underserved Patients: AOA Critical Issues. J Bone Joint Surg Am 2022; 104:e84. [PMID: 35696681 DOI: 10.2106/jbjs.21.01349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Implementation of the Affordable Care Act has increased the number of Americans with health insurance. However, a substantial portion of the population is still considered underserved, including those who are uninsured, underinsured, and those who are enrolled in Medicaid. The patients frequently face substantial access-to-care issues. Many underlying social determinants of health impact this vulnerable, underserved population, and surgeons must understand the nuances of caring for the underserved. There are numerous opportunities to engage with this population, and providing care to the indigent can be rewarding for both the vulnerably underserved patient and their surgeon.
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Affiliation(s)
- Jordan E Handcox
- Department of Orthopaedic Surgery, UT Health San Antonio, San Antonio, Texas
| | - James M Saucedo
- Department of Orthopedics and Sports Medicine, Houston Methodist, Houston, Texas
| | - Ryan A Rose
- Department of Orthopaedic Surgery, UT Health San Antonio, San Antonio, Texas
| | - Fred G Corley
- Department of Orthopaedic Surgery, UT Health San Antonio, San Antonio, Texas
| | - Christina I Brady
- Department of Orthopaedic Surgery, UT Health San Antonio, San Antonio, Texas.,Department of Orthopaedic Surgery, Audie L. Murphy Memorial Veterans' Hospital, San Antonio, Texas
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30
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Mitzman B. Commentary: Leveling the playing field: Imbalances in lung cancer care. J Thorac Cardiovasc Surg 2022. [DOI: 10.1016/j.jtcvs.2022.09.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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31
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Wang Y, Witman AE, Cho DD, Watson ED. Financial Outcomes Associated With the COVID-19 Pandemic in California Hospitals. JAMA HEALTH FORUM 2022; 3:e223056. [PMID: 36218945 PMCID: PMC9508652 DOI: 10.1001/jamahealthforum.2022.3056] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
ImportanceThe COVID-19 pandemic challenged the financial solvency of hospitals, yet there is limited evidence examining hospital financial performance through the first 15 months of the pandemic.ObjectiveTo assess the financial outcomes associated with the COVID-19 pandemic in California hospitals.Design, Setting, and ParticipantsThis cross-sectional study tracked the financial performance of 348 hospitals in California using Hospital Quarterly Financial and Utilization Data from the State of California Office of Statewide Health Planning and Development. Hospital financial performance was examined from January 2019 to June 2021 for all hospitals in aggregate and by safety-net status.ExposuresPre–COVID-19 financial outcomes vs COVID-19 period outcomes.Main Outcomes and MeasuresQuarterly revenues, expenses, and profits.ResultsIn 348 California hospitals, hospital financial performance was highly variable during the COVID-19 pandemic. Losses were reduced by COVID-19 relief funding and strong equities market performance starting in the second quarter of 2020. Non–safety net hospitals maintained positive operating margins throughout the pandemic, while safety-net hospitals experienced large losses. Between the first quarter of 2020 and the second quarter of 2021, California safety-net hospitals’ net operating losses were more than $3.2 billion.Conclusions and RelevanceIn this cross-sectional study of California hospitals, hospital financial performance was tracked between the first quarter of 2019 and the second quarter of 2021. Although hospitals experienced reduced profits between January 2020 and June 2021, the interventions of government assistance programs were able to mitigate more detrimental fiscal consequences. When compared with non–safety net hospitals, safety-net hospitals were confronted with more concentrated financial losses.
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Affiliation(s)
- Yu Wang
- Congdon School of Supply Chain, Business Analytics, and Information Systems, University of North Carolina, Wilmington
| | - Allison E. Witman
- Department of Economics and Finance, University of North Carolina, Wilmington
| | - David D. Cho
- Department of Management, College of Business and Economics, California State University, Fullerton
| | - Ethan D. Watson
- Department of Economics and Finance, University of North Carolina, Wilmington
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Silva TS, Singh A, Sinjali K, Gochi A, Allison-Aipa T, Luca F, Plasencia A, Lum S, Solomon N, Molina C. Spanish-Speaking Status: A Protective Factor in Colorectal Cancer Presentation at a Safety-Net Hospital. J Surg Res 2022; 280:404-410. [PMID: 36041340 DOI: 10.1016/j.jss.2022.06.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 06/16/2022] [Accepted: 06/29/2022] [Indexed: 12/04/2022]
Abstract
INTRODUCTION Lower screening rates and poorer outcomes for colorectal cancer have been associated with Hispanic ethnicity and Spanish-speaking status, respectively. METHODS We reviewed sequential colorectal cancer patients evaluated by the surgical service at a safety-net hospital (SNH) (2016-2019). Insurance type, stage, cancer type, surgery class (elective/urgent), initial surgeon contact setting (outpatient clinic/inpatient consult), operation (resection/diversion), and follow-up were compared by patient-reported primary spoken language. RESULTS Of 157 patients, 85 (54.1%) were men, 91 (58.0%) had colon cancer, 67 (42.7%) primarily spoke Spanish, and late stage (III or IV) presentations occurred in 83 (52.9%) patients. The median age was 58 y, cancer resection was completed in 48 (30.6%) patients, and 51 (32.5%) patients were initially seen as inpatient consults. On univariate analysis, Spanish-speaking status was significantly associated with female sex, Medicaid insurance, being seen as an outpatient consult, and undergoing elective and resection surgery. On multivariable logistic regression, Spanish-speaking patients had higher odds of having Medicaid insurance (AOR 2.28, P = 0.019), receiving a resection (AOR 3.96, P = 0.006), and undergoing an elective surgery (AOR 3.24, P = 0.025). Spanish-speaking patients also had lower odds of undergoing an initial inpatient consult (AOR 0.34, P = 0.046). CONCLUSIONS Spanish-speaking status was associated with a lower likelihood of emergent presentation and need for palliative surgery among SNH colorectal cancer patients. Further research is needed to determine if culturally competent infrastructure in the SNH setting translates into Spanish-speaking status as a potentially protective factor.
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Affiliation(s)
- Trevor S Silva
- Riverside University Health System, Moreno Valley, California
| | - Anika Singh
- Riverside University Health System, Moreno Valley, California
| | - Kiran Sinjali
- University of California Riverside School of Medicine, Riverside, California
| | - Andrea Gochi
- University of California Riverside School of Medicine, Riverside, California
| | - Timothy Allison-Aipa
- Comparative Effectiveness and Clinical Outcomes Research Center (CECORC), Riverside University Health System, Moreno Valley, California
| | - Fabrizio Luca
- Loma Linda University Health, Loma Linda, California
| | - Alexis Plasencia
- Riverside University Health System, Moreno Valley, California; Loma Linda University Health, Loma Linda, California
| | - Sharon Lum
- Riverside University Health System, Moreno Valley, California; University of California Riverside School of Medicine, Riverside, California; Loma Linda University Health, Loma Linda, California
| | | | - Caba Molina
- Riverside University Health System, Moreno Valley, California; University of California Riverside School of Medicine, Riverside, California; Loma Linda University Health, Loma Linda, California.
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Smith JP, Kressel AB, Grout RW, Weaver B, Cheatham M, Tu W, Li R, Crabb DW, Harris LE, Carlos WG. Poverty, Comorbidity, and Ethnicity: COVID-19 Outcomes in a Safety Net Health System. Ethn Dis 2022; 32:113-122. [PMID: 35497398 DOI: 10.18865/ed.32.2.113] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective To determine if race-ethnicity is correlated with case-fatality rates among low-income patients hospitalized for COVID-19. Research Design Observational cohort study using electronic health record data. Patients All patients assessed for COVID-19 from March 2020 to January 2021 at one safety net health system. Measures Patient demographic and clinical characteristics, and hospital care processes and outcomes. Results Among 25,253 patients assessed for COVID-19, 6,357 (25.2%) were COVID-19 positive: 1,480 (23.3%) hospitalized; 334 (22.6%) required intensive care; and 106 (7.3%) died. More Hispanic patients tested positive (51.8%) than non-Hispanic Black (31.4%) and White patients (16.7%, P<.001]. Hospitalized Hispanic patients were younger, more often uninsured, and less likely to have comorbid conditions. Non-Hispanic Black patients had significantly more diabetes, hypertension, obesity, chronic kidney disease, and asthma (P<.05). Non-Hispanic White patients were older and had more cigarette smoking history, COPD, and cancer. Non-Hispanic White patients were more likely to receive intensive care (29.6% vs 21.1% vs 20.8%, P=.007) and more likely to die (12% vs 7.3% vs 3.5%, P<.001) compared with non-Hispanic Black and Hispanic patients, respectively. Length of stay was similar for all groups. In logistic regression models, Medicaid insurance status independently correlated with hospitalization (OR 3.67, P<.001) while only age (OR 1.076, P<.001) and cerebrovascular disease independently correlated with in-hospital mortality (OR 2.887, P=.002). Conclusions Observed COVID-19 in-hospital mortality rate was lower than most published rates. Age, but not race-ethnicity, was independently correlated with in-hospital mortality. Safety net health systems are foundational in the care of vulnerable patients suffering from COVID-19, including patients from under-represented and low-income groups.
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Affiliation(s)
- Joseph P Smith
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep & Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN.,Eskenazi Health, Indianapolis, IN
| | - Amy B Kressel
- Department of Medicine, Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN.,Eskenazi Health, Indianapolis, IN
| | - Randall W Grout
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN.,Eskenazi Health, Indianapolis, IN.,Regenstrief Institute, Indianapolis, IN
| | - Bree Weaver
- Department of Medicine, Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN.,Eskenazi Health, Indianapolis, IN.,Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN
| | - Megan Cheatham
- Department of Medicine, Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN.,Eskenazi Health, Indianapolis, IN
| | - Wanzhu Tu
- Regenstrief Institute, Indianapolis, IN.,Department of Biostatistics & Health Data Science, Indiana University School of Medicine, Indianapolis, IN
| | - Ruohong Li
- Department of Biostatistics & Health Data Science, Indiana University School of Medicine, Indianapolis, IN
| | - David W Crabb
- Department of Medicine, Division of Gastroenterology Hepatology, Indiana University School of Medicine, Indianapolis, IN.,Eskenazi Health, Indianapolis, IN
| | - Lisa E Harris
- Department of Medicine, Division of General Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN.,Eskenazi Health, Indianapolis, IN
| | - William G Carlos
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep & Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN.,Eskenazi Health, Indianapolis, IN
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Edwards GC, Wong SL, Russell MC, Winslow ER, Shaffer VO, Pawlik TM. Society for Surgery of the Alimentary Tract Health Care Quality and Outcomes Committee Webinar: Addressing Disparities. J Gastrointest Surg 2022; 26:997-1005. [PMID: 35318595 DOI: 10.1007/s11605-022-05300-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/09/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Gretchen C Edwards
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandra L Wong
- Department of Surgery, Dartmouth-Hitchcock and Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Maria C Russell
- Department of Surgery, Winship Cancer Institute at Emory University, Atlanta, GA, USA
| | - Emily R Winslow
- Department of Surgery, Medstar Georgetown Medical Center, Washington, DC, USA
| | - Virginia O Shaffer
- Department of Surgery, Winship Cancer Institute at Emory University, Atlanta, GA, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Liu J, Pang EM, Iacob A, Simonian A, Phibbs CS, Profit J. Evaluating Care in Safety Net Hospitals: Clinical Outcomes and Neonatal Intensive Care Unit Quality of Care in California. J Pediatr 2022; 243:99-106.e3. [PMID: 34890584 PMCID: PMC8960349 DOI: 10.1016/j.jpeds.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/22/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To examine the characteristics of safety net (sn) and non-sn neonatal intensive care units (NICUs) in California and evaluate whether the site of care is associated with clinical outcomes. STUDY DESIGN This population-based retrospective cohort study of 34 snNICUs and 104 non-snNICUs included 22 081 infants born between 2014 and 2018 with a birth weight of 401-1500 g or gestational age of 22-29 weeks. Quality of care as measured by the Baby-MONITOR score and rates of survival without major morbidity were compared between snNICUs and non-snNICUs. RESULTS Black and Hispanic infants were cared for disproportionately in snNICUs, where care and outcomes varied widely. We found no significant differences in Baby-Measure Of Neonatal InTensive care Outcomes Research (MONITOR) scores (z-score [SD]: snNICUs, -0.31 [1.3]; non-snNICUs, 0.03 [1.1]; P = .1). Among individual components, infants in snNICUs exhibited lower rates of human milk nutrition at discharge (-0.64 [1.0] vs 0.27 [0.9]), lower rates of no health care-associated infection (-0.27 [1.1] vs 0.14 [0.9]), and higher rates of no hypothermia on admission (0.39 [0.7] vs -0.25 [1.1]). We found small but significant differences in survival without major morbidity (adjusted rate, 65.9% [95% CI, 63.9%-67.9%] for snNICUs vs 68.3% [95% CI, 67.0%-69.6%] for non-snNICUs; P = .02) and in some of its components; snNICUs had higher rates of necrotizing enterocolitis (3.8% [3.4%-4.3%] vs 3.1% [95% CI, 2.8%-3.4%]) and mortality (95% CI, 7.1% [6.5%-7.7%] vs 6.6% [6.2%-7.0%]). CONCLUSIONS snNICUs achieved similar performance as non-snNICUs in quality of care except for small but significant differences in any human milk at discharge, infection, hypothermia, necrotizing enterocolitis, and mortality.
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Affiliation(s)
- Jessica Liu
- Division of Neonatology, Department of Pediatrics, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA,California Perinatal Quality Care Collaborative, Palo Alto, CA
| | - Emily M. Pang
- Division of Neonatology, Department of Pediatrics, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Alexandra Iacob
- California Perinatal Quality Care Collaborative, Palo Alto, CA,Division of Neonatal/Perinatal Medicine, Department of Pediatrics, School of Medicine, University of California Irvine, Orange, CA
| | - Aida Simonian
- California Perinatal Quality Care Collaborative, Palo Alto, CA
| | - Ciaran S. Phibbs
- Division of Neonatology, Department of Pediatrics, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA,Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Healthcare System, Menlo Park, CA
| | - Jochen Profit
- Division of Neonatology, Department of Pediatrics, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA; California Perinatal Quality Care Collaborative, Palo Alto, CA.
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Powell WR, Hansmann KJ, Carlson A, Kind AJ. Evaluating How Safety-Net Hospitals Are Identified: Systematic Review and Recommendations. Health Equity 2022; 6:298-306. [PMID: 35557553 PMCID: PMC9081065 DOI: 10.1089/heq.2021.0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 11/12/2022] Open
Abstract
Objective: To systematically review how safety-net hospitals' status is identified and defined, discuss current definitions' limitations, and provide recommendations for a new classification and evaluation framework. Data Sources: Safety-net hospital-related studies in the MEDLINE database published before May 16, 2019. Study Design: Systematic review of the literature that adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data Collection/Extraction Methods: We followed standard selection protocol, whereby studies went through an abstract review followed by a full-text screening for eligibility. For each included study, we extracted information about the identification method itself, including the operational definition, the dimension(s) of disadvantage reflected, study objective, and how safety-net status was evaluated. Principal Findings: Our review identified 132 studies investigating safety-net hospitals. Analysis of identification methodologies revealed substantial heterogeneity in the ways disadvantage is defined, measured, and summarized at the hospital level, despite a 4.5-fold increase in studies investigating safety-net hospitals for the past decade. Definitions often exclusively used low-income proxies captured within existing health system data, rarely incorporated external social risk factor measures, and were commonly separated into distinct safety-net status categories when analyzed. Conclusions: Consistency in research and improvement in policy both require a standard definition for identifying safety-net hospitals. Yet no standardized definition of safety-net hospitals is endorsed and existing definitions have key limitations. Moving forward, approaches rooted in health equity theory can provide a more holistic framework for evaluating disadvantage at the hospital level. Furthermore, advancements in precision public health technologies make it easier to incorporate detailed neighborhood-level social determinants of health metrics into multidimensional definitions. Other countries, including the United Kingdom and New Zealand, have used similar methods of identifying social need to determine more accurate assessments of hospital performance and the development of policies and targeted programs for improving outcomes.
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Affiliation(s)
- W. Ryan Powell
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kellia J. Hansmann
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Andrew Carlson
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Amy J.H. Kind
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Geriatrics Division, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Iribarne A, Young MN. Assessing Quality of Cardiac Surgical Care at Safety-Net Hospitals. Ann Thorac Surg 2022; 114:709-710. [PMID: 35331703 DOI: 10.1016/j.athoracsur.2022.02.069] [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: 02/16/2022] [Accepted: 02/19/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Alexander Iribarne
- Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon NH 03766.
| | - Michael N Young
- Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon NH 03766
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Shashikumar SA, Waken RJ, Aggarwal R, Wadhera RK, Joynt Maddox KE. Three-Year Impact Of Stratification In The Medicare Hospital Readmissions Reduction Program. Health Aff (Millwood) 2022; 41:375-382. [PMID: 35254934 DOI: 10.1377/hlthaff.2021.01448] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The Medicare Hospital Readmissions Reduction Program (HRRP) financially penalizes hospitals with high readmission rates. In fiscal year 2019 the program was changed to account for the association between social risk and high readmission rates. The new approach stratifies hospitals into five groups by hospitals' proportion of patients dually enrolled in Medicare and Medicaid, and it evaluates performance within each stratum instead of within the national cohort. Its impact on hospitals caring for vulnerable populations has not been studied. We calculated the change in average annual penalty percentage, before and after stratification, for safety-net hospitals, rural hospitals, and hospitals caring for a high share of Black and Hispanic or Latino patients. We found that stratification by proportion of dual enrollees was associated with a decrease in penalties by -0.09 percentage points at hospitals with the highest proportion of dual enrollees, -0.08 percentage points at rural hospitals, and -0.06 percentage points at hospitals with a large share of Black and Hispanic or Latino patients. Fully adjusted analyses suggest that these patterns were driven by penalty reductions at rural hospitals and hospitals disproportionately serving Black and Hispanic or Latino patients. Given the allocation of fewer penalties to these hospitals, we conclude that the stratification mandate was a modest step toward equity within the HRRP.
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Affiliation(s)
| | - R J Waken
- R. J. Waken, Washington University in St. Louis
| | - Rahul Aggarwal
- Rahul Aggarwal, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Rishi K Wadhera
- Rishi K. Wadhera, Beth Israel Deaconess Medical Center and Harvard Medical School
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Reid LD, Weiss AJ, Fingar KR. Contributors to disparities in postpartum readmission rates between safety-net and non-safety-net hospitals: A decomposition analysis. J Hosp Med 2022; 17:77-87. [PMID: 35504571 DOI: 10.1002/jhm.2769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 10/12/2021] [Accepted: 10/16/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Safety-net hospitals (SNHs) treat more maternal patients with risk factors for postpartum readmission. OBJECTIVE To assess how patient, hospital, and community characteristics explain the SNH/non-SNH disparity in postpartum readmission rates. DESIGN A linear probability model assessed covariates associated with postpartum readmissions. Oaxaca-Blinder decomposition estimates quantified the contribution of covariates to the SNH/non-SNH disparity in postpartum readmission rates. SETTING Healthcare Cost and Utilization Project 2016-2018 State Inpatient Databases from 25 states. PARTICIPANTS 3.5 million maternal delivery stays. MEASUREMENTS The outcome was inpatient readmission within 42 days of delivery. SNHs had a share of Medicaid/uninsured stays in the top quartile. A range of patient, hospital, and community characteristics was considered as covariates. RESULTS The unadjusted postpartum readmission rate was 4.2 per 1000 index deliveries higher at SNHs than at non-SNHs (19.1 vs. 14.9, p < .001). Adjustment reduced the risk difference to 0.65 per 1000 (95% confidence interval [CI]: -0.14, 1.44). Patient (66%), hospital (14%), and community (4%) characteristics explained 84% of the disparity. The single largest contributors to the disparity were race/ethnicity (20%), hypertension (12%), hospital preterm delivery rate (10%), and preterm delivery (7%). Collectively, patient comorbidities explained 31% of the disparity. CONCLUSION Higher postpartum readmission rates at SNHs versus non-SNHs were largely due to differences in the patient mix rather than hospital factors. Hospital initiatives are needed to reduce the risk of postpartum readmissions among SNH patients. Improving factors that contribute to the disparity, including underlying health conditions and health inequities associated with race, requires enduring investments in public health.
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Affiliation(s)
- Lawrence D Reid
- Agency for Healthcare Research and Quality, Rockville, Maryland, USA
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Thomas A, Borrup K, Campbell BT. Moving Toward a Better Understanding of Why Interpersonal Firearm Violence Increased During the Pandemic. JAMA Netw Open 2022; 5:e2146116. [PMID: 35133440 DOI: 10.1001/jamanetworkopen.2021.46116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Arielle Thomas
- Firearm Clinical Scholar in Residence, American College of Surgeons, Chicago, Illinois
| | - Kevin Borrup
- Injury Prevention Center, Connecticut Children's Medical Center, Hartford
| | - Brendan T Campbell
- Pediatric Surgery and Injury Prevention Center, Connecticut Children's Medical Center, Hartford
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Davis MA, Gichoya JW, Banerjee I, Sung D, Newsome J, Vey BL, Gerard R, Khan F, Zavaletta V, Mazaheri S, Heilbrun ME. Balancing the Scales: An Analysis of Social Determinants of Health, Radiology Report Acuity, and Radiology Staffing Models in an Academic Health System. J Am Coll Radiol 2022; 19:172-177. [PMID: 35033306 DOI: 10.1016/j.jacr.2021.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/31/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Social determinants of health, including race and insurance status, contribute to patient outcomes. In academic health systems, care is provided by a mix of trainees and faculty members. The optimal staffing ratio of trainees to faculty members (T/F) in radiology is unknown but may be related to the complexity of patients requiring care. Hospital characteristics, patient demographics, and radiology report findings may serve as markers of risk for poor outcomes because of patient complexity. METHODS Descriptive characteristics of each hospital in an urban five-hospital academic health system, including payer distribution and race, were collected. Radiology department T/F ratios were calculated. A natural language processing model was used to classify multimodal report findings into nonacute, acute, and critical, with report acuity calculated as the fraction of acute and critical findings. Patient race, payer type, T/F ratio, and report acuity score for hospital 1, a safety net hospital, were compared with these factors for hospitals 2 to 5. RESULTS The fraction of patients at hospital 1 who are Black (79%) and have Medicaid insurance (28%) is significantly higher than at hospitals 2 to 5 (P < .0001), with the exception of hospital 3 (80.1% black). The T/F ratio of 1.37 at hospital 1 as well as its report acuity (28.9%) were significantly higher (P < .0001 for both). CONCLUSIONS T/F ratio and report acuity are highest at hospital 1, which serves the most at-risk patient population. This suggests a potential overreliance on trainees at a site whose patients may require the greatest expertise to optimize care.
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Affiliation(s)
- Melissa A Davis
- Assistant Professor, Director of Quality, Emory University, School of Medicine, Atlanta, Georgia.
| | | | - Imon Banerjee
- Assistant Professor, Emory University, School of Medicine, Atlanta, Georgia
| | | | - Janice Newsome
- Associate Professor, Chief of Interventional Radiology, Emory University, School of Medicine, Atlanta, Georgia
| | - Brianna L Vey
- Resident, Emory University, School of Medicine, Atlanta, Georgia
| | - Roger Gerard
- Resident, Emory University, School of Medicine, Atlanta, Georgia
| | - Fiza Khan
- Resident, Emory University, School of Medicine, Atlanta, Georgia
| | - Vaz Zavaletta
- Fellow, Emory University, School of Medicine, Atlanta, Georgia
| | - Sina Mazaheri
- Resident, Emory University, School of Medicine, Atlanta, Georgia
| | - Marta E Heilbrun
- Associate Professor, Vice-Chair of Quality, Emory University, School of Medicine, Atlanta, Georgia
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Li Y, Hockenberry JM, Chen J, Cimiotti JP. Registered nurses: can our supply meet the demand during a disaster? BMC Nurs 2022; 21:7. [PMID: 34983516 PMCID: PMC8724595 DOI: 10.1186/s12912-021-00794-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Death and destructions are often reported during natural disasters; yet little is known about how hospitals operate during disasters and if there are sufficient resources available for hospitals to provide ongoing care during these catastrophic events. The purpose of this study was to determine if the State of New Jersey had a supply of registered nurses (RNs) that was sufficient to meet the needs of hospitalized patients during a natural disaster - Hurricane Sandy. METHODS Secondary data were used to forecast the demand and supply of New Jersey RNs during Hurricane Sandy. Data sources from November 2011 and 2012 included the State Inpatient Databases (SID), American Hospital Association (AHA) Annual Survey on hospital characteristics and staffing data from New Jersey Department of Health. Three models were used to estimate the RN shortage for each hospital, which was the difference between the demand and supply of RN full-time equivalents. RESULTS Data were available on 66 New Jersey hospitals, more than half of which experienced a shortage of RNs during Hurricane Sandy. For hospitals with a RN shortage in ICUs, a 20% increase in observed RN supply was needed to meet the demand; and a 10% increase in observed RN supply was necessary to meet the demand for hospitals with a RN shortage in non-ICUs. CONCLUSION Findings from this study suggest that many hospitals in New Jersey had a shortage of RNs during Hurricane Sandy. Efforts are needed to improve the availability of nurse resources during a natural disaster.
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Affiliation(s)
- Yin Li
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta, Georgia, 30322-4027, USA.
| | - Jason M Hockenberry
- Department of Health Policy and Management, School of Public Health, Yale University, 60 College Street, New Haven, CT, 06520-0834, USA
| | | | - Jeannie P Cimiotti
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta, Georgia, 30322-4027, USA
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Liu M, Figueroa JF, Song Y, Wadhera RK. Mortality and Postdischarge Acute Care Utilization for Cardiovascular Conditions at Safety-Net Versus Non-Safety-Net Hospitals. J Am Coll Cardiol 2022; 79:83-87. [PMID: 34763956 PMCID: PMC8741642 DOI: 10.1016/j.jacc.2021.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/07/2021] [Accepted: 10/12/2021] [Indexed: 01/07/2023]
Affiliation(s)
- Michael Liu
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Trends in Substance Use Disorder-related Admissions at a Safety-net Hospital, 2008 - 2020. J Addict Med 2022; 16:360-363. [PMID: 34380984 PMCID: PMC8828803 DOI: 10.1097/adm.0000000000000896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Safety-net hospitals disproportionately care for people with substance use disorders (SUDs), yet little is known about trends in hospital admissions related to specific substances. This study uses electronic health record data to describe trends in substance-specific admissions at a Midwest urban safety-net hospital. METHODS We included all admissions from 2008 through 2020 and defined them as non-SUD (N = 154,477) or SUD-related (N = 63,667). We described patient characteristics and trends in substance-specific admissions. We estimated the association of SUD diagnoses with discharge against medical advice and length of stay using logistic regression and generalized linear models. RESULTS Between 2008 and 2020, SUD-related admissions increased from 23.1% to 32.9% of total admissions. Admissions related to SUD had significantly more comorbidities than non-SUD-related admissions (4.7 vs 3.5, P < 0.001). Among illicit substances, cocaine-related admissions were the most common in 2008 (3.9% of total admissions, 17.2% of SUD admissions) whereas psychostimulants (eg, methamphetamines) were the most common in 2020 (7.8% of total admissions, 23.8% of SUD admissions). SUD-related hospitalizations had higher rates of against medical advice discharge (3.8%; 95% CI 3.6-3.9 vs 1.4%; 95% CI 1.3-1.4) and longer length of stay (6.3 days; 95% CI: 6.2-6.3 vs 5.3 days; 95% CI: 5.3-5.4) than non-SUD-related admissions. CONCLUSIONS Over the study period, the proportion of admissions related to substance use rose to approximately one third of all admissions, driven by a rapidly increasing share of psychostimulant-related admissions. Identifying substance use patterns quickly using electronic health record data can help safety-net hospitals meet the needs of their patients and improve outcomes.
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Yang Z, Huckfeldt P, Escarce JJ, Sood N, Nuckols T, Popescu I. Did the Hospital Readmissions Reduction Program Reduce Readmissions without Hurting Patient Outcomes at High Dual-Proportion Hospitals Prior to Stratification? INQUIRY: THE JOURNAL OF HEALTH CARE ORGANIZATION, PROVISION, AND FINANCING 2022; 59:469580211064836. [PMID: 35317683 PMCID: PMC8949751 DOI: 10.1177/00469580211064836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Since the implementation of Medicare’s Hospital Readmissions Reduction Program (HRRP), safety-net hospitals have received a disproportionate share of financial penalties for excess readmissions, raising concerns about the fairness of the policy. In response, the HRRP now stratifies hospitals into five quintiles by low-income Medicare (dual Medicare–Medicaid eligible) stay proportion and compares readmission rates within quintiles. To better understand the potential effects of the revised policy, we used difference-in-differences models to compare changes in 30-day readmission, 30-day mortality, and 90th-day community-dwelling rates after discharge of fee-for-service Medicare beneficiaries hospitalized for acute myocardial infarction, heart failure and pneumonia during 2007-2014, for hospitals in the highest (N = 677) and lowest (N = 678) dual-proportion quintiles before and after the original HRRP implementation in fiscal year 2013. We find that high dual-proportion hospitals lowered readmissions for all three conditions, while their patients’ health outcomes remained largely stable. We also find that for heart failure, high dual-proportion hospitals reduced readmissions more than low dual-proportion hospitals, albeit with a relative increase in mortality. Contrary to concerns about fairness, our findings imply that, under the original HRRP, high dual-proportion hospitals improved readmissions performance generally without adverse effects on patients’ health. Whether these gains could be retained under the new policy should be closely monitored.
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Affiliation(s)
- Zhiyou Yang
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Peter Huckfeldt
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Jose J. Escarce
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Neeraj Sood
- Department of Health Policy and Management, University of Southern California Sol Price School of Public Policy, Los Angeles, CA, USA
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - Teryl Nuckols
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ioana Popescu
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
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Soriano KK, Toogood P. Effect of Institution and COVID-19 on Access to Adult Arthroplasty Surgery. Arthroplast Today 2022; 14:86-89. [PMID: 35097168 PMCID: PMC8784453 DOI: 10.1016/j.artd.2022.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 12/27/2021] [Accepted: 01/15/2022] [Indexed: 12/03/2022] Open
Abstract
Background Although insurance status is important to patients’ ability to access care, it varies significantly by race, age, and socioeconomic status. Novel coronavirus disease 2019 (COVID-19) negatively impacted access to care, while simultaneously widening pre-existing health-care disparities. The purpose of the present study was to document this phenomena within orthopedics. Methods Patients undergoing hip or knee arthroplasty at two medical centers in San Francisco, California, were evaluated. One cohort came from the University of California San Francisco (UCSF), a tertiary center, and the other from Zuckerberg San Francisco General Hospital (ZSFGH), a safety-net hospital. Patients who underwent arthroplasty before the pandemic (March 2020) and those after pandemic declaration were evaluated. Patient demographics, surgical wait times, and operative volumes were compared. Results Two-hundred sixty-nine (pre-COVID, 184; post-COVID, 85) cases at UCSF and 63 (pre-COVID, 47; post-COVID, 16) cases at ZSFGH met inclusion criteria. Patients at ZSFGH had a significantly higher body mass index, were more often racial minorities, and were less likely to speak English. Patients at ZSFGH were less likely to have private insurance. A comparison of case volumes showed a larger decrease at ZSFGH than at UCSF after COVID. Wait times between the two sites before and after COVID showed a larger increase in wait times at ZSFGH. Notably, wait times at ZSFGH before COVID were more than double the wait times at UCSF after COVID. Conclusions COVID-19 worsened access to primary hip and knee arthroplasties at two academic medical centers in San Francisco. The pandemic also worsened pre-existing disparities. Racial minorities, non-English speakers, and those with nonprivate insurance were affected the most.
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Ryan P, Furniss A, Breslin K, Everhart R, Hanratty R, Rice J. Assessing and Augmenting Predictive Models for Hospital Readmissions With Novel Variables in an Urban Safety-net Population. Med Care 2021; 59:1107-1114. [PMID: 34593712 DOI: 10.1097/mlr.0000000000001653] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The performance of existing predictive models of readmissions, such as the LACE, LACE+, and Epic models, is not established in urban safety-net populations. We assessed previously validated predictive models of readmission performance in a socially complex, urban safety-net population, and if augmentation with additional variables such as the Area Deprivation Index, mental health diagnoses, and housing access improves prediction. Through the addition of new variables, we introduce the LACE-social determinants of health (SDH) model. METHODS This retrospective cohort study included adult admissions from July 1, 2016, to June 30, 2018, at a single urban safety-net health system, assessing the performance of the LACE, LACE+, and Epic models in predicting 30-day, unplanned rehospitalization. The LACE-SDH development is presented through logistic regression. Predictive model performance was compared using C-statistics. RESULTS A total of 16,540 patients met the inclusion criteria. Within the validation cohort (n=8314), the Epic model performed the best (C-statistic=0.71, P<0.05), compared with LACE-SDH (0.67), LACE (0.65), and LACE+ (0.61). The variables most associated with readmissions were (odds ratio, 95% confidence interval) against medical advice discharge (3.19, 2.28-4.45), mental health diagnosis (2.06, 1.72-2.47), and health care utilization (1.94, 1.47-2.55). CONCLUSIONS The Epic model performed the best in our sample but requires the use of the Epic Electronic Health Record. The LACE-SDH performed significantly better than the LACE and LACE+ models when applied to a safety-net population, demonstrating the importance of accounting for socioeconomic stressors, mental health, and health care utilization in assessing readmission risk in urban safety-net patients.
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Affiliation(s)
- Patrick Ryan
- Department of General Internal Medicine
- Ambulatory Care Services, Community Health Services, Denver Health & Hospital Authority, Denver
- Department of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus
| | - Anna Furniss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus
| | - Kristin Breslin
- Ambulatory Care Services, Community Health Services, Denver Health & Hospital Authority, Denver
| | - Rachel Everhart
- Ambulatory Care Services, Community Health Services, Denver Health & Hospital Authority, Denver
- Department of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus
| | - Rebecca Hanratty
- Department of General Internal Medicine
- Ambulatory Care Services, Community Health Services, Denver Health & Hospital Authority, Denver
- Department of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus
| | - John Rice
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
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Tang L, Kim C, Paik C, West J, Hasday S, Su P, Martinez E, Zhou S, Clark B, O'Dell K, Chambers TN. Tracheostomy Outcomes in COVID-19 Patients in a Low Resource Setting. Ann Otol Rhinol Laryngol 2021; 131:1217-1223. [PMID: 34852660 DOI: 10.1177/00034894211062542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES COVID-19 predominately affects safety net hospitals. Tracheostomies improve outcomes and decrease length of stay for COVID-19 patients. Our objectives are to determine if (1) COVID-19 tracheostomies have similar complication and mortality rates as non-COVID-19 tracheostomies and (2) to determine the effectiveness of our tracheostomy protocol at a safety net hospital. METHODS Patients who underwent tracheostomy at Los Angeles County Hospital between August 2009 and August 2020 were included. Demographics, SARS-CoV-2 status, body mass index (BMI), Charlson Co-morbidity Index (CCI), length of intubation, complication rates, decannulation rates, and 30-day all-cause mortality versus tracheostomy related mortality rates were all collected. RESULTS Thirty-eight patients with COVID-19 and 130 non-COVID-19 patients underwent tracheostomies. Both groups were predominately male with similar BMI and CCI, though the COVID-19 patients were more likely to be Hispanic and intubated for a longer time (P = .034 and P < .0001, respectively). Both groups also had similar, low intraoperative complications at 2% to 3% and comparable long-term post-operative complications. However, COVID-19 patients had more perioperative complications within 7 days of surgery (P < .01). Specifically, they were more likely to have perioperative bleeding at their tracheostomy sites (P = .03) and long-term post-operative mucus plugging (P < .01). However, both groups had similar 30-day mortality rates. There were no incidences of COVID-19 transmission to healthcare workers. CONCLUSIONS COVID-19 tracheostomies are safe for patients and healthcare workers. Careful attention should be paid to suctioning to prevent mucus plugging. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Liyang Tang
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Celeste Kim
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Connie Paik
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Jonathan West
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Steven Hasday
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Peiyi Su
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Eduardo Martinez
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Sheng Zhou
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Bhavishya Clark
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Karla O'Dell
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Tamara N Chambers
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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49
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Li Y, Cimiotti JP. Nurse Staffing and Patient Outcomes During a Natural Disaster. JOURNAL OF NURSING REGULATION 2021. [DOI: 10.1016/s2155-8256(21)00114-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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50
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Madhusudhana S, Gates M, Singh D, Grover P, Indaram M, Cheng AL. Impact of Psychological Distress on Treatment Timeliness in Oncology Patients at a Safety-Net Hospital. J Natl Compr Canc Netw 2021:jnccn20058. [PMID: 34380112 DOI: 10.6004/jnccn.2021.7018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 01/28/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Psychological distress is common in patients with cancer. Distress can affect patients' engagement with treatment. We examined the relationship between psychological distress and treatment timeliness in a sample of adult oncology patients at a safety-net hospital. METHODS A retrospective review was conducted of all patients screened for distress at a first outpatient oncology visit between March 1, 2014, and December 31, 2015 (n=500). The analytic sample (n=96) included patients with a new cancer diagnosis and a curative-intent treatment plan for lymphoma (stage I-IV), solid tumor malignancy (stage I-III), or head and neck cancer (stage I-IVb). Distress was measured using the Hospital Anxiety and Depression Scale. Using Poisson regression, we determined the effects of depression and anxiety on treatment timeliness. Patient age, sex, race/ethnicity, insurance type, cancer site, and cancer stage were included as covariates. RESULTS Mean patient age was 54 years. The median treatment initiation interval was 28 days. Clinically significant anxiety was present in 34% of the sample, and clinically significant depression in 15%. Greater symptom severity in both anxiety and depression were associated with a longer treatment initiation interval after controlling for demographics and disease factors. The average days to treatment (DTT) was 4 days longer for patients with elevated anxiety scores and for those with elevated depression scores compared with those without. Overall survival was not associated with anxiety, depression, or DTT. CONCLUSIONS In this safety-net patient sample, greater psychological distress was associated with slower time to treatment. As of writing, this is a new finding in the literature, and as such, replication studies utilizing diverse samples and distress measurement tools are needed.
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Affiliation(s)
- Sheshadri Madhusudhana
- 1University of Missouri-Kansas City School of Medicine and
- 2Truman Medical Centers, Kansas City, Missouri
| | | | | | - Punita Grover
- 4University of Cincinnati Medical Center, Cincinnati, Ohio; and
| | | | - An-Lin Cheng
- 1University of Missouri-Kansas City School of Medicine and
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