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Mehta B, Ho K, Gibbons JAB, Ling V, Goodman S, Parks M, Ravi B, Wang F, Ibrahim S, Cram P. Understanding the Influence of Single Payer Health Insurance on Socioeconomic Disparities in Total Hip Arthroplasty (THA) Utilization: A Transnational Analysis. J Am Acad Orthop Surg 2024:00124635-990000000-00959. [PMID: 38713873 DOI: 10.5435/jaaos-d-23-01178] [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: 12/07/2023] [Accepted: 12/24/2023] [Indexed: 05/09/2024] Open
Abstract
OBJECTIVE Access to care varies between countries. It is theorized that income-based disparities in access may be reduced in countries with universal health insurance relative to the United States, but data are currently limited. We hypothesized that income-based differences in total hip arthroplasty (THA) utilization and outcomes would be larger in the United States than in Canada. METHODS We retrospectively compared all patients undergoing THA from 2012 to 2018 in Pennsylvania, the United States, and Ontario, Canada. We compared age-standardized and sex-standardized per-capita THA utilization in the United States and Canada overall and across different income strata, where income strata were defined by neighborhood income quintile. We also examined income-based differences in rates of 1-year revision, 90-day mortality, and 90-day readmission. RESULTS Overall THA utilization per 10,000 people per year was higher across all income groups in Pennsylvania compared with Ontario (15.1 versus 8.8, P < 0.001 in lowest-income quintile; 21.4 versus 12.6, P < 0.001 in highest-income quintile). Income-based differences in utilization in the highest-income vs lowest-income quintile groups were greater in Ontario (43.2%) than Pennsylvania (41.7%). The adjusted odds for the lowest-income group compared with the highest-income group of 1-year revision were greater in Ontario compared with Pennsylvania (P = 0.03), and risk of 90-day mortality and 90-day readmission was similar between the regions. CONCLUSION Income-based differences in THA utilization were more notable in Ontario than in Pennsylvania. In addition, patients in low-income communities in Ontario were at equal or greater risk relative to high-income community patients for adverse outcomes compared with patients in Pennsylvania. Income-based disparities in THA utilization and outcomes were smaller in the United States than in Canada, in contrast to what might be expected. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Bella Mehta
- From the Department of Medicine, Hospital for Special Surgery, New York, NY (Mehta, Goodman, and Parks), the Department of Medicine, Weill Cornell Medicine, New York, NY (Mehta, Ho, Goodman, Parks, and Wang), the Columbia University Vagelos College of Physicians & Surgeons, New York, NY (Gibbons), the Ontario Institute for Cancer Research, Toronto, ON (Ling), the Sunnybrook Health Sciences Centre, Toronto, ON (Ravi), the Northwell Health, New York, NY (Ibrahim), the The University of Texas Medical Branch, Galveston, TX (Cram), and the Faculty of Medicine, University of Toronto, Toronto, ON (Cram)
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Duffy J, Jones P, McNaughton CD, Ling V, Matelski J, Hsia RY, Landon B, Cram P. Emergency department utilization, admissions, and revisits in the United States (New York), Canada (Ontario), and New Zealand: A retrospective cross-sectional analysis. Acad Emerg Med 2023; 30:946-954. [PMID: 37062045 PMCID: PMC10871149 DOI: 10.1111/acem.14738] [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: 11/08/2022] [Revised: 04/01/2023] [Accepted: 04/10/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND Emergency department (ED) utilization is a significant concern in many countries, but few population-based studies have compared ED use. Our objective was to compare ED utilization in New York (United States), Ontario (Canada), and New Zealand (NZ). METHODS A retrospective cross-sectional analysis of all ED visits between January 1, 2016, and September 30, 2017, for adults ≥18 years using data from the State Emergency Department and Inpatient Databases (New York), the National Ambulatory Care Reporting System and Discharge Abstract Data (Ontario), and the National Non-Admitted Patient Collection and the National Minimum Data Set (New Zealand). Outcomes included age- and sex-standardized per-capita ED utilization (overall and stratified by neighborhood income), ED disposition, and ED revisit and hospitalization within 30 days of ED discharge. RESULTS There were 10,998,371 ED visits in New York, 8,754,751 in Ontario, and 1,547,801 in New Zealand. Patients were older in Ontario (mean age 51.1 years) compared to New Zealand (50.3) and New York (48.7). Annual sex- and age-standardized per-capita ED utilization was higher in Ontario than New York or New Zealand (443.2 vs. 404.0 or 248.4 visits per 1000 population/year, respectively). In all countries, ED utilization was highest for residents of the lowest income quintile neighborhoods. The proportion of ED visits resulting in hospitalization was higher in New Zealand (34.5%) compared to New York (20.8%) and Ontario (12.8%). Thirty-day ED revisits were higher in Ontario (27.0%) than New Zealand (18.6%) or New York (21.4%). CONCLUSIONS Patterns of ED utilization differed widely across three high-income countries. These differences highlight the varying approaches that our countries take with respect to urgent visits, suggest opportunities for shared learning through international comparisons, and raise important questions about optimal approaches for all countries.
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Affiliation(s)
- Juliana Duffy
- Division of Emergency Medicine, Department of Medicine: University of Toronto, Toronto Ontario, Canada
| | - Peter Jones
- Department of Surgery, School of Medicine, University of Auckland, Auckland, New Zealand
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand
| | - Candace D. McNaughton
- Division of Emergency Medicine, Department of Medicine: University of Toronto, Toronto Ontario, Canada
- ICES (formerly known as the Institute for Comparative and Evaluative Sciences), Toronto, Ontario, Canada
- Biostatistics Research Unit, Toronto General Hospital, Toronto, Ontario, Canada
| | - Vicki Ling
- ICES (formerly known as the Institute for Comparative and Evaluative Sciences), Toronto, Ontario, Canada
| | - John Matelski
- Biostatistics Research Unit, Toronto General Hospital, Toronto, Ontario, Canada
| | - Renee Y. Hsia
- Department of Emergency Medicine, UCSF, San Francisco, California, United States of America
- Philip R. Lee Institute for Health Policy, UCSF, San Francisco, California, United States of America
| | - Bruce Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Peter Cram
- ICES (formerly known as the Institute for Comparative and Evaluative Sciences), Toronto, Ontario, Canada
- Department of Internal Medicine, UTMB, Galveston, Texas, United States of America
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Landon BE, Hatfield LA, Bakx P, Banerjee A, Chen YC, Fu C, Gordon M, Heine R, Huang N, Ko DT, Lix LM, Novack V, Pasea L, Qiu F, Stukel TA, Uyl-de Groot C, Yan L, Weinreb G, Cram P. Differences in Treatment Patterns and Outcomes of Acute Myocardial Infarction for Low- and High-Income Patients in 6 Countries. JAMA 2023; 329:1088-1097. [PMID: 37014339 PMCID: PMC10074220 DOI: 10.1001/jama.2023.1699] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 02/01/2023] [Indexed: 04/05/2023]
Abstract
Importance Differences in the organization and financing of health systems may produce more or less equitable outcomes for advantaged vs disadvantaged populations. We compared treatments and outcomes of older high- and low-income patients across 6 countries. Objective To determine whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries. Design, Setting, and Participants Serial cross-sectional cohort study of all adults aged 66 years or older hospitalized with acute myocardial infarction from 2013 through 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. Exposures Being in the top and bottom quintile of income within and across countries. Main Outcomes and Measures Thirty-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay, and readmission rates. Results We studied 289 376 patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843 046 hospitalized with non-STEMI (NSTEMI). Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. For instance, 30-day mortality among patients admitted with STEMI in the Netherlands was 10.2% for those with high income vs 13.1% for those with low income (difference, -2.8 percentage points [95% CI, -4.1 to -1.5]). One-year mortality differences for STEMI were even larger than 30-day mortality, with the highest difference in Israel (16.2% vs 25.3%; difference, -9.1 percentage points [95% CI, -16.7 to -1.6]). In all countries, rates of cardiac catheterization and percutaneous coronary intervention were higher among high- vs low-income populations, with absolute differences ranging from 1 to 6 percentage points (eg, 73.6% vs 67.4%; difference, 6.1 percentage points [95% CI, 1.2 to 11.0] for percutaneous intervention in England for STEMI). Rates of coronary artery bypass graft surgery for patients with STEMI in low- vs high-income strata were similar but for NSTEMI were generally 1 to 2 percentage points higher among high-income patients (eg, 12.5% vs 11.0% in the US; difference, 1.5 percentage points [95% CI, 1.3 to 1.8 ]). Thirty-day readmission rates generally also were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income patients. Conclusions and Relevance High-income individuals had substantially better survival and were more likely to receive lifesaving revascularization and had shorter hospital lengths of stay and fewer readmissions across almost all countries. Our results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems.
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Affiliation(s)
- Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Laura A. Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Pieter Bakx
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, the Netherlands
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, England
- Department of Cardiology, University College London Hospitals, London, England
| | - Yu-Chin Chen
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Christina Fu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Michal Gordon
- Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel
| | - Renaud Heine
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, the Netherlands
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Dennis T. Ko
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lisa M. Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
| | - Victor Novack
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Laura Pasea
- Institute of Health Informatics, University College London, London, England
| | - Feng Qiu
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Therese A. Stukel
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Carin Uyl-de Groot
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, the Netherlands
| | - Lin Yan
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
| | - Gabe Weinreb
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Peter Cram
- ICES, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Texas Medical Branch, Galveston
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Mehta B, Ho K, Ling V, Goodman S, Parks M, Ravi B, Banerjee S, Wang F, Ibrahim S, Cram P. Are Income-based Differences in TKA Use and Outcomes Reduced in a Single-payer System? A Large-database Comparison of the United States and Canada. Clin Orthop Relat Res 2022; 480:1636-1645. [PMID: 35543485 PMCID: PMC9384923 DOI: 10.1097/corr.0000000000002207] [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: 10/12/2021] [Accepted: 03/21/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Income-based differences in the use of and outcomes in TKA have been studied; however, it is not known if different healthcare systems affect this relationship. Although Canada's single-payer healthcare system is assumed to attenuate the wealth-based differences in TKA use observed in the United States, empirical cross-border comparisons are lacking. QUESTIONS/PURPOSES (1) Does TKA use differ between Pennsylvania, USA, and Ontario, Canada? (2) Are income-based disparities in TKA use larger in Pennsylvania or Ontario? (3) Are TKA outcomes (90-day mortality, 90-day readmission, and 1-year revision rates) different between Pennsylvania and Ontario? (4) Are income-based disparities in TKA outcomes larger in Pennsylvania or Ontario? METHODS We identified all patients hospitalized for primary TKA in this cross-border retrospective analysis, using administrative data for 2012 to 2018, and we found a total of 161,244 primary TKAs in Ontario and 208,016 TKAs in Pennsylvania. We used data from the Pennsylvania Health Care Cost Containment Council, Harrisburg, PA, USA, and the ICES (formally the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada. We linked patient-level data to the respective census data to determine community-level income using ZIP Code or postal code of residence and stratified patients into neighborhood income quintiles. We compared TKA use (age and gender, standardized per 10,000 population per year) for patients residing in the highest-income versus the lowest-income quintile neighborhoods. Similarly secondary outcomes 90-day mortality, 90-day readmission, and 1-year revision rates were compared between the two regions and analyzed by income groups. RESULTS TKA use was higher in Pennsylvania than in Ontario overall and for all income quintiles (lowest income quartile: 31 versus 18 procedures per 10,000 population per year; p < 0.001; highest income quartile: 38 versus 23 procedures per 10,000 population per year; p < 0.001). The relative difference in use between the highest-income and lowest-income quintile was larger in Ontario (28% higher) than in Pennsylvania (23% higher); p < 0.001. Patients receiving TKA in Pennsylvania were more likely to be readmitted within 90 days and were more likely to undergo revision within the first year than patients in Ontario, but there was no difference in mortality at 1 year. When comparing income groups, there were no differences between the countries in 90-day mortality, readmission, or 1-year revision rates (p > 0.05). CONCLUSION These results suggest that universal health insurance through a single-payer may not reduce the income-based differences in TKA access that are known to exist in the United States. Future studies are needed determine if our results are consistent across other geographic regions and other surgical procedures. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Bella Mehta
- Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Kaylee Ho
- Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, NY, USA
| | | | - Susan Goodman
- Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Michael Parks
- Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Bheeshma Ravi
- ICES, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Holland Centre, Toronto, Ontario, USA
| | - Samprit Banerjee
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Fei Wang
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Said Ibrahim
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Peter Cram
- ICES, Toronto, Ontario, Canada
- Department of Medicine, University of Texas Medical Branch, Galveston, TX, USA
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Manner PA. Editor's Spotlight/Take 5: Are Income-based Differences in TKA Use and Outcomes Reduced in a Single-payer System? A Large-database Comparison of the United States and Canada. Clin Orthop Relat Res 2022; 480:1631-1635. [PMID: 35916660 PMCID: PMC9384937 DOI: 10.1097/corr.0000000000002343] [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] [Received: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Paul A Manner
- Senior Editor, Clinical Orthopaedics and Related Research ®, Park Ridge, IL, USA
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Quiroz JC, Brieger D, Jorm LR, Sy RW, Falster MO, Gallego B. An Observational Study of Clinical and Health System Factors Associated With Catheter Ablation and Early Ablation Treatment for Atrial Fibrillation in Australia. Heart Lung Circ 2022; 31:1269-1276. [PMID: 35623999 DOI: 10.1016/j.hlc.2022.04.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/20/2022] [Accepted: 04/18/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate clinical and health system factors associated with receiving catheter ablation (CA) and earlier ablation for non-valvular atrial fibrillation (AF). METHODS We used hospital administrative data linked with death registrations in New South Wales, Australia for patients with a primary diagnosis of AF between 2009 and 2017. Outcome measures included receipt of CA versus not receiving CA during follow-up (using Cox regression) and receipt of early ablation (using logistic regression). RESULTS Cardioversion during index admission (hazard ratio [HR] 1.96; 95% CI 1.75-2.19), year of index admission (HR 1.07; 1.07; 95% CI 1.05-1.10), private patient status (HR 2.65; 95% CI 2.35-2.97), and living in more advantaged areas (HR 1.18; 95% CI 1.13-1.22) were associated with a higher likelihood of receiving CA. A history of congestive heart failure, hypertension, diabetes, and myocardial infarction were associated with a lower likelihood of receiving CA. Private patient status (odds ratio [OR] 2.04; 95% CI 1.59-2.61), cardioversion during index admission (OR 1.25; 95% CI 1.0-1.57), and history of diabetes (OR 1.6; 95% CI 1.06-2.41) were associated with receiving early ablation. CONCLUSIONS Beyond clinical factors, private patients are more likely to receive CA and earlier ablation than their public counterparts. Whether the earlier access to ablation procedures in private patients is leading to differences in outcomes among patients with atrial fibrillation remains to be explored.
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Affiliation(s)
- Juan C Quiroz
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia.
| | - David Brieger
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Michael O Falster
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Blanca Gallego
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
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Cram P, Hatfield LA, Bakx P, Banerjee A, Fu C, Gordon M, Heine R, Huang N, Ko D, Lix LM, Novack V, Pasea L, Qiu F, Stukel TA, de Groot CU, Yan L, Landon B. Variation in revascularisation use and outcomes of patients in hospital with acute myocardial infarction across six high income countries: cross sectional cohort study. BMJ 2022; 377:e069164. [PMID: 35508312 PMCID: PMC9066381 DOI: 10.1136/bmj-2021-069164] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To compare treatment and outcomes for patients admitted to hospital with a primary diagnosis of ST elevation or non-ST elevation myocardial infarction (STEMI or NSTEMI) in six high income countries with very different healthcare delivery systems. DESIGN Retrospective cross sectional cohort study. SETTING Patient level administrative data from the United States, Canada (Ontario and Manitoba), England, the Netherlands, Israel, and Taiwan. PARTICIPANTS Adults aged 66 years and older admitted to hospital with STEMI or NSTEMI between 1 January 2011 and 31 December 2017. OUTCOMES MEASURES The three categories of outcomes were coronary revascularisation (percutaneous coronary intervention or coronary artery bypass graft surgery), mortality, and efficiency (hospital length of stay and 30 day readmission). Rates were standardised to the age and sex distribution of the US acute myocardial infarction population in 2017. Outcomes were assessed separately for STEMI and NSTEMI. Performance was evaluated longitudinally (over time) and cross sectionally (between countries). RESULTS The total number of hospital admissions ranged from 19 043 in Israel to 1 064 099 in the US. Large differences were found between countries for all outcomes. For example, the proportion of patients admitted to hospital with STEMI who received percutaneous coronary intervention in hospital during 2017 ranged from 36.9% (England) to 78.6% (Canada; 71.8% in the US); use of percutaneous coronary intervention for STEMI increased in all countries between 2011 and 2017, with particularly large rises in Israel (48.4-65.9%) and Taiwan (49.4-70.2%). The proportion of patients with NSTEMI who underwent coronary artery bypass graft surgery within 90 days of admission during 2017 was lowest in the Netherlands (3.5%) and highest in the US (11.7%). Death within one year of admission for STEMI in 2017 ranged from 18.9% (Netherlands) to 27.8% (US) and 32.3% (Taiwan). Mean hospital length of stay in 2017 for STEMI was lowest in the Netherlands and the US (5.0 and 5.1 days) and highest in Taiwan (8.5 days); 30 day readmission for STEMI was lowest in Taiwan (11.7%) and the US (12.2%) and highest in England (23.1%). CONCLUSIONS In an analysis of myocardial infarction in six high income countries, all countries had areas of high performance, but no country excelled in all three domains. Our findings suggest that countries could learn from each other by using international comparisons of patient level nationally representative data.
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Affiliation(s)
- Peter Cram
- Department of Medicine, University of Texas Medical Branch, Galveston, TX, USA
- ICES, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Pieter Bakx
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, University College London Hospitals, London, UK
| | - Christina Fu
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Michal Gordon
- Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel
| | - Renaud Heine
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Dennis Ko
- ICES, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Schulich Heart Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel
| | - Laura Pasea
- Institute of Health Informatics, University College London, London, UK
| | | | - Therese A Stukel
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Carin Uyl de Groot
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands
| | - Lin Yan
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Bruce Landon
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Cram P, Cohen ME, Ko C, Landon BE, Hall B, Jackson TD. Surgical Outcomes in Canada and the United States: An Analysis of the ACS-NSQIP Clinical Registry. World J Surg 2022; 46:1039-1050. [PMID: 35102437 PMCID: PMC9929717 DOI: 10.1007/s00268-022-06444-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND There has been longstanding uncertainty over whether lower healthcare spending in Canada might be associated with inferior outcomes for hospital-based care. We hypothesized that mortality and surgical complication rates would be higher for patients who underwent four common surgical procedures in Canada as compared to the US. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective cohort study of all adults who underwent hip fracture repair, colectomy, pancreatectomy, or spine surgery in 96 Canadian and 585 US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) between January 1, 2015 and December 31, 2019. We compared patients with respect to demographic characteristics and comorbidity. We then compared unadjusted and adjusted outcomes within 30-days of surgery for patients in Canada and the US including: (1) Mortality; (2) A composite constituting 1-or-more of the following complications (cardiac arrest; myocardial infarction; pneumonia; renal failure/; return to operating room; surgical site infection; sepsis; unplanned intubation). RESULTS Our hip fracture cohort consisted of 21,166 patients in Canada (22.3%) and 73,817 in the US (77.7%), for colectomy 21,279 patients in Canada (8.9%) and 218,307 (91.1%), for pancreatectomy 873 (7.8%) in Canada and 12,078 (92.2%) in the US, and for spine surgery 14,088 (5.3%) and 252,029 (94.7%). Patient sociodemographics and comorbidity were clinically similar between jurisdictions. In adjusted analyses odds of death was significantly higher in Canada for two procedures (colectomy (OR 1.22; 95% CI 1.044-1.424; P = .012) and pancreatectomy (OR 2.11; 95% CI 1.26-3.56; P = .005)) and similar for hip fracture and spine surgery. Odds of the composite outcome were significantly higher in Canada for all 4 procedures, largely driven by higher risk of cardiac events and post-operative infections. CONCLUSIONS We found evidence of higher rates of mortality and surgical complications within 30-days of surgery for patients in Canada as compared to the US.
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Affiliation(s)
- Peter Cram
- Department of Medicine, University of Toronto, Toronto, ON, Canada. .,Division of General Internal Medicine and Geriatrics, Sinai Health System and University Health Network, Toronto, ON, Canada. .,ICES, Toronto, ON, Canada. .,University of Texas Medical Branch, Galveston, TX, USA.
| | | | - Clifford Ko
- American College of Surgeons, Chicago, IL, USA,UCLA Department of Surgery, Los Angeles, CA, USA,Los Angeles VA Medical Center, Los Angeles, CA, USA
| | - Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School and Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Bruce Hall
- American College of Surgeons, Chicago, IL, USA,Department of Surgery, School of Medicine, Washington University, St Louis, MO, USA,St Louis VA Medical Center, St Louis, MO, USA,BJC Healthcare, St Louis, MO, USA
| | - Timothy D. Jackson
- Department of Surgery, University of Toronto, Toronto, Canada,Division of General Surgery, University Health Network, Toronto, ON, Canada
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Cram P, Selker H, Carnahan J, Romero-Brufau S, Fischer MA. Getting to 100%: Research Priorities and Unanswered Questions to Inform the US Debate on Universal Health Insurance Coverage. J Gen Intern Med 2022; 37:949-953. [PMID: 35060003 PMCID: PMC8904700 DOI: 10.1007/s11606-021-07234-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Abstract
A majority of Americans favor universal health insurance, but there is uncertainty over how best to achieve this goal. Whatever the insurance design that is implemented, additional details that must be considered include breadth of services covered, restrictions and limits on volumes of services, cost-sharing for individuals, and pricing. In the hopes that research can inform this ongoing debate, we review evidence supporting different models for achieving universal coverage in the US and identify areas where additional research and stakeholder input is needed. Key areas in need of further research include how care should be organized, how costs can be reduced, and what healthcare services universal insurance should cover.
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Affiliation(s)
- Peter Cram
- Department of Internal Medicine, Medical Branch, University of Texas, 301 University Blvd, Galveston, TX, 77555, USA. .,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - Harry Selker
- Institute for Clinical Research and Health Policy Studies, Tufts University School of Medicine, Boston, MA, USA
| | - Jennifer Carnahan
- Indiana University School of Medicine, Indianapolis, IN, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA
| | - Santiago Romero-Brufau
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA.,Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael A Fischer
- Division of Pharmacoepidemiology, Brigham and Women's Hospital, Boston, MA, USA
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de Oliveira Costa J, Pearson SA, Elshaug AG, van Gool K, Jorm LR, Falster MO. Rates of Low-Value Service in Australian Public Hospitals and the Association With Patient Insurance Status. JAMA Netw Open 2021; 4:e2138543. [PMID: 34889943 PMCID: PMC8665371 DOI: 10.1001/jamanetworkopen.2021.38543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Low-value services have limited or no benefit to patients. Rates of low-value service in public hospitals may vary by patient insurance status, given that there may be different financial incentives for treatment of privately insured patients. OBJECTIVE To assess the variation in rates of 5 low-value services performed in Australian public hospitals according to patient funding status (ie, private or public). DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study analyzed New South Wales public hospital data from January 2013 to June 2018. Patients included in the sample were over age 18 years and eligible to receive low-value services based on diagnoses and concomitant procedures. Data analysis was conducted from June to December 2020. MAIN OUTCOMES AND MEASURES Hospital-specific rates of low-value knee arthroscopic debridement, vertebroplasty for osteoporotic spinal fractures, hyperbaric oxygen therapy, oophorectomy with hysterectomy, and laparoscopic uterine nerve ablation for chronic pelvic pain were measured. For each measure, rates within each public hospital were compared by patient funding status descriptively and using multilevel models. RESULTS A total of 219 862 inpatients were included in analysis from 58 public hospitals across the 5 measures. A total of 38 365 (22 904 [59.7%] women; 12 448 [32.4%] aged 71-80 years) were eligible for knee arthroscopic debridement for osteoarthritis; 2520 (1924 [76.3%] women; 662 [26.3%] aged 71-80 years), vertebroplasty for osteoporotic spinal fractures; 162 285 (82 046 [50.6%] women; 28 255 [17.4%] aged 61-70 years), hyperbaric oxygen therapy; 15 916 (7126 [44.8%] aged 41-50 years), oophorectomy with hysterectomy; and 776 (327 [42.1%] aged 18-30 years), uterine nerve ablation for chronic pelvic pain. Overall rates of low-value services varied considerably between measures, with the lowest rate for hyperbaric oxygen therapy (0.3 procedures per 1000 inpatients [47 of 158 220 eligible inpatients]) and the highest for vertebroplasty (30.8 procedures per 1000 eligible patients [77 of 2501 eligible inpatients]). There was significant variation in rates between hospitals, with a few outlying hospitals (ie, <10), particularly for knee arthroscopy (range from 1.8 to 21.0 per 1000 eligible patients) and vertebroplasty (range from 13.1 to 70.4 per 1000 eligible patients), with higher numerical rates of low-value services among patients with private insurance than for those without. However, there was no association overall between patient insurance status and low-value services. Overall differences in rates among those with and without private insurance by individual procedure type were not statistically significant. CONCLUSIONS AND RELEVANCE There was significant variation in rates of low-value services in public hospitals. While there was no overall association between private insurance and rate of low-value services, private insurance may be associated with low-value service rates in some hospitals. Further exploration of factors specific to local hospitals and practices are needed to reduce this unnecessary care.
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Affiliation(s)
- Juliana de Oliveira Costa
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, Kensington, New South Wales, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, Kensington, New South Wales, Australia
| | - Adam G. Elshaug
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kees van Gool
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Louisa R. Jorm
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, Kensington, New South Wales, Australia
| | - Michael O. Falster
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, Kensington, New South Wales, Australia
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