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Diaz A, Pawlik TM. Poverty and Its Impact on Surgical Care. Adv Surg 2024; 58:35-47. [PMID: 39089785 DOI: 10.1016/j.yasu.2024.04.003] [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: 08/04/2024]
Abstract
In this article, the authors explore the intricate relationship between poverty and surgical care, underscoring its multifaceted nature and its profound impact on access and outcomes. Poverty extends beyond financial constraints to encompass barriers related to healthcare infrastructure, geographic isolation, education, mental health, and social determinants of health, resulting in persistent disparities in access to high-quality surgical care, especially for those in persistently impoverished areas and access-sensitive surgical conditions. Additionally, the authors delve into the complex intersection of poverty, race, and ethnicity, emphasizing the heightened risks faced by minority patients in surgical care.
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Affiliation(s)
- Adrian Diaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH 43210, USA.
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Akinyemi OA, Weldeslase TA, Fasokun M, Griffiths Y, Andine T, Odusanya E, Williams M, Hughes K, Cornwell E, Fullum T. The impact of the affordable care act on access to bariatric surgery in Maryland. Am J Surg 2024; 235:115609. [PMID: 38171943 DOI: 10.1016/j.amjsurg.2023.12.021] [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: 10/30/2023] [Revised: 11/30/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION This study aims to investigate the influence of the Affordable Care Act (ACA) on the utilization of Roux-en-Y gastric bypass (RYGB) procedures in Maryland. METHODS Using the Maryland State Inpatient Database, this retrospective study compared all patients undergoing RYGB during the pre-ACA (2007-2009) and post-ACA (2018-2020) periods, including patient demographic factors, pre-existing conditions, and socioeconomic factors. RESULTS A total of 16,494 RYGB procedures were performed during the study period, of which 12,089 (73.3 %) were post-ACA. This was a 179.2 % increase in patients undergoing RYGB post-ACA; nearly triple that of the pre-ACA period. There was a significant decrease in uninsured patients (5.6 %-1.5 %, p < 0.01) an increase in Black patients (32.1 %-46.8 %, p < 0.01) and Medicaid beneficiaries (6.0 % pre-ACA to 17.8 % post-ACA, p < 0.01). There were significant reductions in adverse outcomes (long hospital stays, hemorrhage, GIT leaks, and mortality) across all insurance types (all p < 0.01). CONCLUSION The ACA increased access to RYGB procedures, especially in Black and Medicaid recipients in Maryland, enhancing healthcare across all insurance types.
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Affiliation(s)
- Oluwasegun A Akinyemi
- Department of Surgery Outcomes Research Center, Howard University College of Medicine, Washington, DC, USA.
| | - Terhas A Weldeslase
- Department of Surgery Outcomes Research Center, Howard University College of Medicine, Washington, DC, USA
| | - Mojisola Fasokun
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, USA
| | - Yasmin Griffiths
- Department of Surgery Outcomes Research Center, Howard University College of Medicine, Washington, DC, USA
| | - Tsion Andine
- Department of Surgery Outcomes Research Center, Howard University College of Medicine, Washington, DC, USA
| | - Eunice Odusanya
- Department of Surgery Outcomes Research Center, Howard University College of Medicine, Washington, DC, USA
| | - Mallory Williams
- Department of Surgery, Howard University College of Medicine, Washington, DC, USA
| | - Kakra Hughes
- Department of Surgery, Howard University College of Medicine, Washington, DC, USA
| | - Edward Cornwell
- Department of Surgery, Howard University College of Medicine, Washington, DC, USA
| | - Terrence Fullum
- Department of Surgery, Howard University College of Medicine, Washington, DC, USA
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Sirianno MP, Mustian MN. Beyond the headlines: The impact of the affordable care act on equitable access to bariatric surgery. Am J Surg 2024; 235:115692. [PMID: 38458831 DOI: 10.1016/j.amjsurg.2024.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/10/2024]
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Schpero WL, Takvorian SU, Blickstein D, Shafquat A, Liu J, Chatterjee AK, Lamont EB, Chatterjee P. Association Between State Medicaid Policies and Accrual of Black or Hispanic Patients to Cancer Clinical Trials. J Clin Oncol 2024:JCO2301149. [PMID: 39052944 DOI: 10.1200/jco.23.01149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 04/14/2024] [Accepted: 05/10/2024] [Indexed: 07/27/2024] Open
Abstract
PURPOSE It is unknown whether Medicaid expansion under the Affordable Care Act (ACA) or state-level policies mandating Medicaid coverage of the routine costs of clinical trial participation have ameliorated longstanding racial and ethnic disparities in cancer clinical trial enrollment. METHODS We conducted a retrospective, cross-sectional difference-in-differences analysis examining the effect of Medicaid expansion on rates of enrollment for Black or Hispanic nonelderly adults in nonobservational, US cancer clinical trials using data from Medidata's Rave platform for 2012-2019. We examined heterogeneity in this effect on the basis of whether states had pre-existing mandates requiring Medicaid coverage of the routine costs of clinical trial participation. RESULTS The study included 47,870 participants across 1,353 clinical trials and 344 clinical trial sites. In expansion states, the proportion of participants who were Black or Hispanic increased from 16.7% before expansion to 17.2% after Medicaid expansion (0.5 percentage point [PP] change [95% CI, -1.1 to 2.0]). In nonexpansion states, this proportion increased from 19.8% before 2014 (when the first states expanded eligibility under the ACA) to 20.4% after 2014 (0.6 PP change [95% CI, -2.3 to 3.5]). These trends yielded a nonsignificant difference-in-differences estimate of 0.9 PP (95% CI, -2.6 to 4.4). Medicaid expansion was associated with a 5.3 PP (95% CI, 1.9 to 8.7) increase in the enrollment of Black or Hispanic participants in states with mandates requiring Medicaid coverage of the routine costs of trial participation, but not in states without mandates (-0.3 PP [95% CI, -4.5 to 3.9]). CONCLUSION Medicaid expansion was not associated with a significant increase in the proportion of Black or Hispanic oncology trial participants overall, but was associated with an increase specifically in states that mandated Medicaid coverage of the routine costs of trial participation.
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Affiliation(s)
- William L Schpero
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Medical College, Cornell University, New York, NY
- Center for Health Equity, Cornell University, New York, NY
| | - Samuel U Takvorian
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | | | | | - Jingshu Liu
- Medidata AI, a Dassault Systèmes Company, New York, NY
| | | | | | - Paula Chatterjee
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Jarosinski MC, Kennedy JN, Iyer S, Tzeng E, Eslami M, Sridharan ND, Reitz KM. Contemporary National Incidence and Outcomes of Acute Limb Ischemia. Ann Vasc Surg 2024:S0890-5096(24)00469-2. [PMID: 39067849 DOI: 10.1016/j.avsg.2024.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 05/02/2024] [Accepted: 06/02/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Acute Limb Ischemia (ALI) is a morbid and deadly diagnosis. However, existing epidemiologic studies describing ALI predate the introduction of the Affordable Care Act in 2010 and direct oral anticoagulants in 2011. Thus, we synergized the National Inpatient Sample (NIS) and United States (U.S.) Census to define contemporary trends in the incidence, treatment, and outcomes of ALI in the US. METHODS We included emergent admissions of adults with primary diagnosis of lower extremity ALI in survey-weighted NIS data (2005-2020). Mann-Kendal trend test evaluated ALI incidence (primary outcome), anticoagulation usage, insurance coverage, revascularization type, and in-hospital amputation/death. Multivariable logistic regression quantified covariate associations with in-hospital amputation/death. RESULTS Of 582,322,862 estimated hospitalizations in the NIS, 227,440 met inclusion criteria (mean age 68.80 years, 49.94% women, 76.66% White). ALI incidence peaked in 2006 (7.16/100,000 person-years) but has declined since 2015 to 4.16/100,000 person-years in 2020 (ptrend=.008). Endovascular revascularization, anticoagulation, and Medicaid coverage increased, while self-pay insurance decreased (ptrend<.05). Amputation rates significantly decreased from 8.04% to 6.54% (ptrend=.01) while death rate remained at 5.59% (ptrend=.16) over the study period. Pre-hospitalization anticoagulation was associated with decreased amputation (aOR=0.74 [95%CI 0.65-0.84]) and death (aOR=0.50 [95%CI 0.43-0.57]). When controlling for covariates, women had a higher risk of death (aOR=1.17 [95%CI 1.07-1.27], p<.0001), while Black patients had a higher risk of amputation (aOR=1.24 [95%CI 1.10-1.41], p<.0001). CONCLUSIONS Our U.S. population based epidemiological study demonstrates that ALI incidence and in-hospital amputation rates are decreasing, while mortality remains unchanged. We further highlight the ongoing need for ALI investigation specifically as it relates to access to care, antithrombotic therapy use, treatment strategy, and strategies to combat gender and racial disparities.
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Affiliation(s)
| | - Jason N Kennedy
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Stuthi Iyer
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mohammad Eslami
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
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Wagner CS, Hitchner MK, Plana NM, Morales CZ, Salinero LK, Barrero CE, Pontell ME, Bartlett SP, Taylor JA, Swanson JW. Incomes to Outcomes: A Global Assessment of Disparities in Cleft and Craniofacial Treatment. Cleft Palate Craniofac J 2024:10556656241249821. [PMID: 38700320 DOI: 10.1177/10556656241249821] [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: 05/05/2024] Open
Abstract
OBJECTIVE Recent investigations focused on health equity have enumerated widespread disparities in cleft and craniofacial care. This review introduces a structured framework to aggregate findings and direct future research. DESIGN Systematic review was performed to identify studies assessing health disparities based on race/ethnicity, payor type, income, geography, and education in cleft and craniofacial surgery in high-income countries (HICs) and low/middle-income countries (LMICs). Case reports and systematic reviews were excluded. Meta-analysis was conducted using fixed-effect models for disparities described in three or more studies. SETTING N/A. PATIENTS Patients with cleft lip/palate, craniosynostosis, craniofacial syndromes, and craniofacial trauma. INTERVENTIONS N/A. RESULTS One hundred forty-seven articles were included (80% cleft, 20% craniofacial; 48% HIC-based). Studies in HICs predominantly described disparities (77%,) and in LMICs focused on reducing disparities (42%). Level II-IV evidence replicated delays in cleft repair, alveolar bone grafting, and cranial vault remodeling for non-White and publicly insured patients in HICs (Grades A-B). Grade B-D evidence from LMICs suggested efficacy of community-based speech therapy and remote patient navigation programs. Meta-analysis demonstrated that Black patients underwent craniosynostosis surgery 2.8 months later than White patients (P < .001) and were less likely to undergo minimally-invasive surgery (OR 0.36, P = .002). CONCLUSIONS Delays in cleft and craniofacial surgical treatment are consistently identified with high-level evidence among non-White and publicly-insured families in HICs. Multiple tactics to facilitate patient access and adapt multi-disciplinary case in austere settings are reported from LMICs. Future efforts including those sharing tactics among HICs and LMICs hold promise to help mitigate barriers to care.
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Affiliation(s)
- Connor S Wagner
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Michaela K Hitchner
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Natalie M Plana
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Carrie Z Morales
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
- Center for Surgical Health, Department of Surgery, Penn Medicine, USA
| | - Lauren K Salinero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Carlos E Barrero
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Matthew E Pontell
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Scott P Bartlett
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Jesse A Taylor
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
| | - Jordan W Swanson
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, USA
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Schmidt S, Jacobs MA, Kim J, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. Presentation Acuity and Surgical Outcomes for Patients With Health Insurance Living in Highly Deprived Neighborhoods. JAMA Surg 2024; 159:411-419. [PMID: 38324306 PMCID: PMC10851138 DOI: 10.1001/jamasurg.2023.7468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/14/2023] [Indexed: 02/08/2024]
Abstract
Importance Insurance coverage expansion has been proposed as a solution to improving health disparities, but insurance expansion alone may be insufficient to alleviate care access barriers. Objective To assess the association of Area Deprivation Index (ADI) with postsurgical textbook outcomes (TO) and presentation acuity for individuals with private insurance or Medicare. Design, Setting, and Participants This cohort study used data from the National Surgical Quality Improvement Program (2013-2019) merged with electronic health record data from 3 academic health care systems. Data were analyzed from June 2022 to August 2023. Exposure Living in a neighborhood with an ADI greater than 85. Main Outcomes and Measures TO, defined as absence of unplanned reoperations, Clavien-Dindo grade 4 complications, mortality, emergency department visits/observation stays, and readmissions, and presentation acuity, defined as having preoperative acute serious conditions (PASC) and urgent or emergent cases. Results Among a cohort of 29 924 patients, the mean (SD) age was 60.6 (15.6) years; 16 424 (54.9%) were female, and 13 500 (45.1) were male. A total of 14 306 patients had private insurance and 15 618 had Medicare. Patients in highly deprived neighborhoods (5536 patients [18.5%]), with an ADI greater than 85, had lower/worse odds of TO in both the private insurance group (adjusted odds ratio [aOR], 0.87; 95% CI, 0.76-0.99; P = .04) and Medicare group (aOR, 0.90; 95% CI, 0.82-1.00; P = .04) and higher odds of PASC and urgent or emergent cases. The association of ADIs greater than 85 with TO lost significance after adjusting for PASC and urgent/emergent cases. Differences in the probability of TO between the lowest-risk (ADI ≤85, no PASC, and elective surgery) and highest-risk (ADI >85, PASC, and urgent/emergent surgery) scenarios stratified by frailty were highest for very frail patients (Risk Analysis Index ≥40) with differences of 40.2% and 43.1% for those with private insurance and Medicare, respectively. Conclusions and Relevance This study found that patients living in highly deprived neighborhoods had lower/worse odds of TO and higher presentation acuity despite having private insurance or Medicare. These findings suggest that insurance coverage expansion alone is insufficient to overcome health care disparities, possibly due to persistent barriers to preventive care and other complex causes of health inequities.
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Affiliation(s)
- Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
| | - Michael A. Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
- UT Health Physicians Business Intelligence and Data Analytics, University of Texas Health San Antonio, San Antonio
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jonathan C. Silverstein
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio
- University Health, San Antonio, Texas
- Department of Primary Care and Rural Medicine, School of Medicine, Texas A&M University, Bryan
- Department of Medical Physiology, School of Medicine, Texas A&M University, Bryan
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Lemont B. The impact of Medicaid expansion and travel distance on access to transplantation. JOURNAL OF HEALTH ECONOMICS 2024; 94:102858. [PMID: 38232446 DOI: 10.1016/j.jhealeco.2024.102858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/03/2024] [Accepted: 01/09/2024] [Indexed: 01/19/2024]
Abstract
Most transplant centers require candidates be insured before they can join the waitlist for a deceased donor organ. After the Affordable Care Act, many uninsured Americans gained improved access to Medicaid. I examine the effect of this increase in access to insurance and find that Medicaid expansions significantly increase Medicaid-insured waitlist registrations by 39% and deceased donor transplants received by 44%, but the increase in registrations is larger for candidates who live closer to a transplant center. Additionally I show that most of these registrations would have been privately insured otherwise but provide suggestive evidence that this is better explained by improved access to subsidized private coverage due to other ACA reforms than from candidates with private coverage before the ACA switching to Medicaid coverage after expansion. This suggests that although the ACA improved access to the transplantation system, access is still limited for candidates who live far from centers.
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Affiliation(s)
- Bethany Lemont
- Department of Economics, Ohio University, Athens, OH, USA; Appalachian Institute to Advance Health Equity Science, Athens, OH, USA.
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Wu JY, Touponse GC, Theologitis M, Ahmad HS, Zygourakis CC. Demographic and Socioeconomic Trends in Cervical Fusion Utilization from 2004 Through 2021 and the COVID-19 Pandemic. World Neurosurg 2024; 182:e107-e125. [PMID: 38000672 DOI: 10.1016/j.wneu.2023.11.055] [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: 10/31/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Cervical fusion rates increased in the U.S. exponentially 1990-2014, but trends leading up to/during the COVID-19 pandemic have not been fully evaluated by patient socioeconomic status (SES). Here, we provide the most recent, comprehensive characterization of demographic and SES trends in cervical fusions, including during the pandemic. METHODS We collected the following variables on adults undergoing cervical fusions, 1/1/2004-3/31/2021, in Optum's Clinformatics Data Mart: age, Charlson Comorbidity Index, provider's practicing state, gender, race, education, and net worth. We performed multivariate linear and logistic regression to evaluate associations of cervical fusion rates with SES variables. RESULTS Cervical fusion rates increased 2004-2016, then decreased 2016-2020. Proportions of Asian, Black, and Hispanic patients undergoing cervical fusions increased (OR = 1.001,1.001,1.004, P < 0.01), with a corresponding decrease in White patients (OR = 0.996, P < 0.001) over time. There were increases in cervical fusions in higher education groups (OR = 1.006, 1.002, P < 0.001) and lowest net worth group (OR = 1.012, P < 0.001). During the pandemic, proportions of White (OR = 1.015, P < 0.01) and wealthier patients (OR ≥ 1.015, P < 0.01) undergoing cervical fusions increased. CONCLUSIONS We present the first documented decrease in annual cervical surgery rates in the U.S. Our data reveal a bimodal distribution for cervical fusion patients, with racial-minority, lower-net-worth, and highly-educated patients receiving increasing proportions of surgical interventions. White and wealthier patients were more likely to undergo cervical fusions during the COVID-19 pandemic, which has been reported in other areas of medicine but not yet in spine surgery. There is still considerable work needed to improve equitable access to spine care for the entire U.S. POPULATION
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Affiliation(s)
- Janet Y Wu
- School of Medicine, Stanford University, Stanford, California, USA
| | - Gavin C Touponse
- School of Medicine, Stanford University, Stanford, California, USA
| | | | - Hasan S Ahmad
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Corinna C Zygourakis
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA.
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Jacobs MA, Schmidt S, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships Between Race/Ethnicity, Insurance Type, and Neighborhood Deprivation. Ann Surg 2024; 279:246-257. [PMID: 37450703 PMCID: PMC10787813 DOI: 10.1097/sla.0000000000005994] [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: 07/18/2023]
Abstract
OBJECTIVE Develop an ordinal Desirability of Outcome Ranking (DOOR) for surgical outcomes to examine complex associations of Social Determinants of Health. BACKGROUND Studies focused on single or binary composite outcomes may not detect health disparities. METHODS Three health care system cohort study using NSQIP (2013-2019) linked with EHR and risk-adjusted for frailty, preoperative acute serious conditions (PASC), case status and operative stress assessing associations of multilevel Social Determinants of Health of race/ethnicity, insurance type (Private 13,957; Medicare 15,198; Medicaid 2835; Uninsured 2963) and Area Deprivation Index (ADI) on DOOR and the binary Textbook Outcomes (TO). RESULTS Patients living in highly deprived neighborhoods (ADI>85) had higher odds of PASC [adjusted odds ratio (aOR)=1.13, CI=1.02-1.25, P <0.001] and urgent/emergent cases (aOR=1.23, CI=1.16-1.31, P <0.001). Increased odds of higher/less desirable DOOR scores were associated with patients identifying as Black versus White and on Medicare, Medicaid or Uninsured versus Private insurance. Patients with ADI>85 had lower odds of TO (aOR=0.91, CI=0.85-0.97, P =0.006) until adjusting for insurance. In contrast, patients with ADI>85 had increased odds of higher DOOR (aOR=1.07, CI=1.01-1.14, P <0.021) after adjusting for insurance but similar odds after adjusting for PASC and urgent/emergent cases. CONCLUSIONS DOOR revealed complex interactions between race/ethnicity, insurance type and neighborhood deprivation. ADI>85 was associated with higher odds of worse DOOR outcomes while TO failed to capture the effect of ADI. Our results suggest that presentation acuity is a critical determinant of worse outcomes in patients in highly deprived neighborhoods and without insurance. Including risk adjustment for living in deprived neighborhoods and urgent/emergent surgeries could improve the accuracy of quality metrics.
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Affiliation(s)
- Michael A. Jacobs
- Department of Surgery, University of Texas Health San
Antonio, San Antonio, Texas
| | - Susanne Schmidt
- Department of Population Health Sciences, University of
Texas Health San Antonio, San Antonio, Texas
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, and
Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh
Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh,
Pittsburgh, Pennsylvania
- Wolff Center, UPMC, Pittsburgh, Pennsylvania
| | - Karyn B. Stitzenberg
- Department of Surgery, University of North Carolina, Chapel
Hill, North Carolina
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The
University of Texas Health Science Center at Houston, Houston, Texas
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University
of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of
Texas Health San Antonio, San Antonio, Texas
| | - Laura S. Manuel
- UT Health Physicians Business Intelligence and Data
Analytics, University of Texas Health San Antonio, San Antonio, Texas
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of
Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Paula K. Shireman
- Department of Surgery, University of Texas Health San
Antonio, San Antonio, Texas
- Departments of Primary Care & Rural Medicine and
Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas
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Nogueira LM, Boffa DJ, Jemal A, Han X, Yabroff KR. Medicaid Expansion Under the Affordable Care Act and Early Mortality Following Lung Cancer Surgery. JAMA Netw Open 2024; 7:e2351529. [PMID: 38214932 PMCID: PMC10787311 DOI: 10.1001/jamanetworkopen.2023.51529] [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: 09/05/2023] [Accepted: 11/27/2023] [Indexed: 01/13/2024] Open
Abstract
Importance Medicaid expansion under the Patient Protection and Affordable Care Act is associated with gains in health insurance coverage, earlier stage diagnosis, and improved survival among patients with cancer. Objective To examine the association of Medicaid expansion with changes in early mortality among adults undergoing surgical resection of non-small cell lung cancer (NSCLC), a setting in which access to care is a major determinant of survival. Design, Setting, and Participants This cohort study used the National Cancer Database to identify 14 984 adults 45 to 64 years of age who underwent surgical resection of NSCLC between 2008 and 2019. Analysis was conducted between March 28, 2021, and September 1, 2023. Exposure State of residence Medicaid expansion status. Main Outcomes and Measures Descriptive statistics were used to compare study population characteristics by Medicaid expansion status of patients' state of residence. Difference-in-differences analyses were used to evaluate the association between Medicaid expansion and postoperative mortality before implementation of the ACA (2008-2013) vs after (2014-2019). Results Among 14 984 adults included, the mean (SD) age was 56.3 (5.1) years, 54.6% were women, and 62.1% lived in Medicaid expansion states. Both 30-day (from 0.97% to 0.26%) and 90-day (from 2.63% to 1.32%) postoperative mortality decreased from before the ACA to after among patients residing in Medicaid expansion states (both P < .001) but not in nonexpansion states (30-day mortality before the ACA, 0.75% vs after the ACA, 0.68%; P = .74; and 90-day mortality before the ACA, 2.43% vs after the ACA, 2.20%; P = .57), leading to a difference-in-differences of -0.64 percentage points (95% CI, -1.19 to -0.08; P = .03) for 30-day mortality and -1.08 percentage points (95% CI, -2.08 to -0.08; P = .03) for 90-day mortality. The difference-in-differences for in-hospital mortality was not significant (P = .34) between expansion states (1.41% before the ACA to 0.77% after the ACA; 0.63 percentage point decrease; P = .004) and nonexpansion states (1.49% before the ACA to 1.20% after the ACA; 0.30 percentage point decrease; P = .29). Conclusions and Relevance In this cohort study of patients with NSCLC, Medicaid expansion was associated with declines in 30- and 90-day postoperative mortality following hospital discharge. These findings suggest that Medicaid expansion may be an effective strategy for improving access to care and cancer outcomes in this population.
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Affiliation(s)
- Leticia M. Nogueira
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Daniel J. Boffa
- Division of Thoracic Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Ahmedin Jemal
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - K. Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
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Fazzone B, Anderson EM, Krebs JR, Weaver ML, Pruitt E, Spratt JR, Shah SK, Scali ST, Huber TS, Upchurch GR, Arnaoutakis G, Cooper MA. Self-pay insurance status is associated with failure of medical therapy in patients with acute uncomplicated type B aortic dissection. Surgery 2023; 174:1476-1482. [PMID: 37718170 DOI: 10.1016/j.surg.2023.08.003] [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: 03/02/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Traditionally, acute uncomplicated type B aortic dissections are managed medically, and acute complicated dissections are managed surgically. Self-pay patients with medically managed acute uncomplicated type B aortic dissections may fare worse than their insured counterparts. METHODS In this single-center, retrospective cohort study, demographics, follow-up, and outcomes of patients with acute type B aortic dissections from 2011 to 2020 were analyzed. RESULTS In total, 159 patients presented with acute type B aortic dissections; 102 were complicated and managed with thoracic endovascular aortic repair, and 57 were uncomplicated and managed medically. A total of 32% (n = 51) were self-pay. Self-pay patients were from areas with worse area deprivation indices (71% vs 63%, P = .024). They more often reported alcohol abuse (28% vs 7%, P < .001), cocaine/methamphetamine use (16% vs 5%, P = .028), and nonadherence to home antihypertensives (35% vs 11%, P < .001). Self-pay patients less often had a primary care physician (65% vs 7%, P < .001) or took antihypertensives before admission (31% vs 58%, P = .003). Self-pay patients frequently required financial assistance at discharge (63%), most often using charity funds (46%). Few patients (7%) qualified for our hospital's financial assistance program, and most (78%) remained uninsured at the first follow-up. Self-pay acute uncomplicated type B aortic dissections patients had the lowest rate of follow-up (31% vs 66%, P < .001) and were more likely to represent emergently (75% vs 0%, P = .033) compared to insured acute uncomplicated type B aortic dissections patients. Self-pay patients were more likely to follow up after thoracic endovascular aortic repair for acute complicated type B aortic dissections (82% vs 31%, P < .001). CONCLUSION Self-pay patients have multiple, interconnected, complex socioeconomic factors that likely influence preadmission risk for dissection and post-discharge adherence to optimal medical management. Further research is needed to clarify treatment strategies in this high-risk group.
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Affiliation(s)
- Brian Fazzone
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Erik M Anderson
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Jonathan R Krebs
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Eric Pruitt
- Department of Surgery, Division of Cardiovascular Surgery, University of Florida, Gainesville, FL
| | - John R Spratt
- Department of Surgery, Division of Cardiovascular Surgery, University of Florida, Gainesville, FL
| | - Samir K Shah
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Salvatore T Scali
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Thomas S Huber
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Gilbert R Upchurch
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - George Arnaoutakis
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Michol A Cooper
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL.
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13
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Shearer E, Bundorf MK. Changes in emergency department use associated with Medicaid expansion under the Affordable Care Act: A comparison of waiver and traditional expansion states. J Am Coll Emerg Physicians Open 2023; 4:e13060. [PMID: 37915356 PMCID: PMC10616539 DOI: 10.1002/emp2.13060] [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: 04/27/2023] [Revised: 09/24/2023] [Accepted: 10/10/2023] [Indexed: 11/03/2023] Open
Abstract
Objective To determine whether changes in emergency department use associated with Medicaid expansions differed between states undergoing waiver and traditional expansions. Methods Design: This study was a cross-sectional difference-in-difference and event studies of Medicaid Expansion among states that expanded during or after 2014. Setting: We used a nationally representative cross-sectional survey from all 50 United States and the District of Columbia from 2010 to 2016. Participants: Adults aged 19-65 years with incomes <138% of the federal poverty level were included. Main Outcomes and Measures: Main outcomes were self-reported emergency department (ED) utilization in the last 12 months. Results Individuals in states across all expansion types were not more likely to report any ED use in the previous year (2.8 percentage point increase [0.0-5.5], P = 0.052) but were more likely to report visiting an ED 2 times or more in the previous year (2.0 [0.0-4.1], P = 0.049) than those in non-expansion states. Individuals in states undergoing traditional expansions likewise were not more likely to report any ED use (2.2 [-0.7 to 1.5], P = 0.136) but were more likely to report visiting an ED 2 times or more in the previous year (2.3 [0.1-4.4], P = 0.038). Conversely, individuals in waiver states were more likely to report increase in any ED use (5.6 [0.3-11.0], P = 0.038), but were not more likely to report use of EDs 2 times or more in the previous year (0.8 [-3.2-4.9], P = 0.688). The differences between traditional and waiver states in any ED use and ED use 2 times or more in the previous 12 months were not statistically significant (P = 0.215 and P = 0.501, respectively). Conclusions Three years after expanding Medicaid under the Affordable Care Act, there is little evidence of differences between traditional and waiver expansion states in changes in any ED use or intensive ED use. Future studies should investigate longer term changes in ED use.
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Affiliation(s)
- Emily Shearer
- Department of Emergency MedicineAlpert School of Medicine at Brown UniversityProvidenceRhode IslandUSA
| | - M. Kate Bundorf
- Sanford School of Public PolicyDuke UniversityDurhamNorth CarolinaUSA
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14
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Ukert B, Giannouchos TV. Association of the affordable care act with racial and ethnic disparities in uninsured emergency department utilization. BMC Health Serv Res 2023; 23:1302. [PMID: 38007468 PMCID: PMC10676572 DOI: 10.1186/s12913-023-10168-5] [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] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 10/17/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND Disparities in uninsured emergency department (ED) use are well documented. However, a comprehensive analysis evaluating how the Affordable Care Act (ACA) may have reduced racial and ethnic disparities is lacking. The goal was to assess the association of the ACA with racial and ethnic disparities in uninsured ED use. METHODS This study used data from the Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) for Georgia, Florida, Massachusetts, and New York from 2011 to 2017. Participants include non-elderly adults between 18 and 64 years old. Outcomes include uninsured rates of ED visits by racial and ethnic groups and stratified by medical urgency using the New York University ED algorithm. Visits were aggregated to year-quarter ED visits per 100,000 population and stratified for non-Hispanic White, non-Hispanic Black, and Hispanic non-elderly adults. Quasi-experimental difference-in-differences and triple differences regression analyses to identify the effect of the ACA and the separate effect of the Medicaid expansion were used comparing uninsured ED visits by race and ethnicity groups pre-post ACA. RESULTS The ACA was associated with a 14% reduction in the rate of uninsured ED visits per 100,000 population (from 10,258 pre-ACA to 8,877 ED visits per 100,000 population post-ACA) overall. The non-Hispanic Black compared to non-Hispanic White disparity decreased by 12.4% (-275.1 ED visits per 100,000) post-ACA. About 60% of the decline in the Black-White disparity was attributed to disproportionate declines in ED visit rates for conditions classified as not-emergent (-93.2 ED visits per 100,000), and primary care treatable/preventable (-64.1 ED visits per 100,000), while the disparity in ED visit rates for injuries and not preventable conditions also declined (-106.57 ED visits per 100,000). All reductions in disparities were driven by the Medicaid expansion. No significant decrease in Hispanic-White disparity was observed. CONCLUSIONS The ACA was associated with fewer uninsured ED visits and reduced the Black-White ED disparity, driven mostly by a reduction in less emergent ED visits after the ACA in Medicaid expansion states. Disparities between Hispanic and non-Hispanic White adults did not decline after the ACA. Despite the positive momentum of declining disparities in uninsured ED visits, disparities, especially among Black people, remain.
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Affiliation(s)
- Benjamin Ukert
- Department of Health Policy and Management, Texas A&M University, 212 Adriance Lab Road, 1266 TAMU, College Station, 77843-1266, USA.
| | - Theodoros V Giannouchos
- Department of Health Policy and Organization, The University of Alabama at Birmingham, 1665 University Boulevard, Birmingham, AL, 35233, USA.
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Tong JKC, Mascuilli T, Wirtalla C, Aarons CB, Saur NM, Mahmoud NN, Karakousis GC, Kelz RR. Evaluating Changes in Surgical Outcomes for Patients With Inflammatory Bowel Disease Following Medicaid Expansion. Inflamm Bowel Dis 2023; 29:1579-1585. [PMID: 36573827 DOI: 10.1093/ibd/izac255] [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: 02/02/2022] [Indexed: 10/05/2023]
Abstract
BACKGROUND Little is known about the impact of Medicaid expansion on the surgical care of inflammatory bowel disease. We sought to determine whether Medicaid expansion is associated with improved postsurgical outcomes for patients with inflammatory bowel disease undergoing a colorectal resection. METHODS We performed a risk-adjusted difference-in-difference study examining postsurgical outcomes for patients ages 26 to 64 with Crohn's disease or ulcerative colitis undergoing a colorectal resection across 15 states that did and did not expand Medicaid before (2012-2013) and after (2016-2018) policy reform. Primary study outcomes included 30-day readmission and postoperative complication. RESULTS Study population included 11 394 patients with inflammatory bowel disease that underwent a colorectal resection. States that underwent Medicaid expansion were associated with a rise in Medicaid enrollment following policy reform (11.8% pre-Medicaid expansion vs 19.7% post-Medicaid expansion). Difference-in-difference analysis revealed a statistically significant lower odds of 30-day readmission in patients undergoing a colorectal resection in expansion states following policy reform relative to patients in nonexpansion states prior to reform (odds ratio, 0.56; 95% confidence interval, 0.36-0.86). No changes in odds of postoperative complication were noted across expansion and nonexpansion states. CONCLUSIONS Medicaid expansion is associated with a rise in Medicaid enrollment in expansion states following policy reform. There were greater improvements in postoperative outcomes associated with patients in expansion states following policy reform relative to patients in nonexpansion states prior to reform, which may have been related to improved perioperative care and medical management.
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Affiliation(s)
- Jason K C Tong
- University of Pennsylvania, Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
- National Clinicians Scholars Veterans Affairs Scholar, Philadelphia, PA, USA
| | - Tory Mascuilli
- University of Pennsylvania, Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
| | - Christopher Wirtalla
- University of Pennsylvania, Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
| | - Cary B Aarons
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania, Department of Surgery, Division of Colon and Rectal Surgery, Philadelphia, PA, USA
| | - Nicole M Saur
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania, Department of Surgery, Division of Colon and Rectal Surgery, Philadelphia, PA, USA
| | - Najjia N Mahmoud
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania, Department of Surgery, Division of Colon and Rectal Surgery, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- University of Pennsylvania, Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Rachel R Kelz
- University of Pennsylvania, Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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16
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Scott JW, Neiman PU, Scott KW, Ibrahim AM, Fan Z, Fendrick AM, Dimick JB. High Deductibles are Associated With Severe Disease, Catastrophic Out-of-Pocket Payments for Emergency Surgical Conditions. Ann Surg 2023; 278:e667-e674. [PMID: 36762565 DOI: 10.1097/sla.0000000000005819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
BACKGROUND Out-of-pocket spending has risen for individuals with private health insurance, yet little is known about the unintended consequences that high levels of cost-sharing may have on delayed clinical presentation and financial outcomes for common emergency surgical conditions. METHODS In this retrospective analysis of claims data from a large commercial insurer (2016-2019), we identified adult inpatient admissions following emergency department presentation for common emergency surgical conditions (eg, appendicitis, cholecystitis, diverticulitis, and intestinal obstruction). Primary exposure of interest was enrollment in a high-deductible health insurance plan (HDHP). Our primary outcome was disease severity at presentation-determined using ICD-10-CM diagnoses codes and based on validated measures of anatomic severity (eg, perforation, abscess, diffuse peritonitis). Our secondary outcome was catastrophic out-of-pocket spending, defined by the World Health Organization as out-of-pocket spending >10% of annual income. RESULTS Among 43,516 patients [mean age 48.4 (SD: 11.9) years; 51% female], 41% were enrolled HDHPs. Despite being younger, healthier, wealthier, and more educated, HDHP enrollees were more likely to present with more severe disease (28.5% vs 21.3%, P <0.001; odds ratio (OR): 1.34, 95% CI: 1.28-1.42]); even after adjusting for relevant demographics (adjusted OR: 1.23, 95% CI: 1.18-1.31). HDHP enrollees were also more likely to incur 30-day out-of-pocket spending that exceeded 10% of annual income (20.8% vs 6.4%, adjusted OR: 3.93, 95% CI: 3.65-4.24). Lower-income patients, Black patients, and Hispanic patients were at highest risk of financial strain. CONCLUSIONS For privately insured patients presenting with common surgical emergencies, high-deductible health plans are associated with increased disease severity at admission and a greater financial burden after discharge-especially for vulnerable populations. Strategies are needed to improve financial risk protection for common surgical emergencies.
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Affiliation(s)
- John W Scott
- Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan Medical School, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Pooja U Neiman
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Kirstin W Scott
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Andrew M Ibrahim
- Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan Medical School, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Zhaohui Fan
- Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan Medical School, Ann Arbor, MI
| | - A Mark Fendrick
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Division of General Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Justin B Dimick
- Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan Medical School, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
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17
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Glance LG, Smith DI, Joynt Maddox KE. Do Anesthesiologists Have a Role in Promoting Equitable Health Care? Anesthesiology 2023; 139:244-248. [PMID: 37552097 DOI: 10.1097/aln.0000000000004672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Affiliation(s)
- Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York; Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York; RAND Health, RAND, Boston, Massachusetts
| | - Daryl I Smith
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Karen E Joynt Maddox
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri; Center for Health Economics and Policy at the Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri
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Ramadan OI, Kelz RR, Sharpe JE, Wirtalla CJ, Keele LJ, Harhay MO, Roberts SE, Wang GJ. Impact of Medicaid expansion on outcomes after abdominal aortic aneurysm repair. J Vasc Surg 2023; 78:648-656.e6. [PMID: 37116595 DOI: 10.1016/j.jvs.2023.04.029] [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: 12/31/2022] [Revised: 04/04/2023] [Accepted: 04/17/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE Lack of insurance has been independently associated with an increased risk of in-hospital mortality after abdominal aortic aneurysm repair, possibly due to worse control of comorbidities and delays in diagnosis and treatment. Medicaid expansion has improved insurance rates and access to care, potentially benefiting these patients. We sought to assess the association between Medicaid expansion and outcomes after abdominal aortic aneurysm repair. METHODS A retrospective analysis of Healthcare Cost and Utilization Project State Inpatient Databases data from 14 states between 2012 and 2018 was conducted. The sample was restricted to first-record abdominal aortic aneurysm repairs in adults under age 65 in states that expanded Medicaid on January 1, 2014 (Medicaid expansion group) or had not expanded before December 31, 2018 (non-expansion group). The Medicaid expansion and non-expansion groups were compared between pre-expansion (2012-2013) and post-expansion (2014-2018) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors, open vs endovascular repair, and standard errors clustered by state. Our primary outcome was in-hospital mortality. Outcomes were stratified by insurance type. RESULTS We examined 8995 patients undergoing abdominal aortic aneurysm repair, including 3789 (42.1%) in non-expansion states and 5206 (57.9%) in Medicaid expansion states. Rates of Medicaid insurance were unchanged in non-expansion states but increased in Medicaid expansion states post-expansion (non-expansion: 10.9% to 9.8%; P = .346; expansion: 9.7% to 19.7%; P < .001). One in 10 patients from both non-expansion and Medicaid expansion states presented with ruptured aneurysms, which did not change over time. Rates of open repair decreased in both non-expansion and Medicaid expansion states over time (non-expansion: 25.1% to 19.2%; P < .001; expansion: 25.2% to 18.4%; P < .001). On adjusted difference-in-differences analysis between expansion and non-expansion states pre-to post-expansion, Medicaid expansion was associated with a 1.02% absolute reduction in in-hospital mortality among all patients (95% confidence interval, -1.87% to -0.17%; P = .019). Additionally, among patients who were either on Medicaid or were uninsured (ie, the patients most likely to be impacted by Medicaid expansion), a larger 4.17% decrease in in-hospital mortality was observed (95% confidence interval, -6.47% to -1.87%; P < .001). In contrast, no significant difference-in-difference in mortality was observed for privately insured patients. CONCLUSIONS Medicaid expansion was associated with decreased in-hospital mortality after abdominal aortic aneurysm repair among all patients and particularly among patients who were either on Medicaid or were uninsured. Our results provide support for improved access to care for patients undergoing abdominal aortic aneurysm repair through Medicaid expansion.
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Affiliation(s)
- Omar I Ramadan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Rachel R Kelz
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - James E Sharpe
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | | | - Luke J Keele
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Michael O Harhay
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sanford E Roberts
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Peck GL, Kuo YH, Hudson SV, Gracias VH, Roy JA, Strom BL. Decreased Emergency Cholecystectomy and Case Fatality Rate, Not Explained by Expansion of Medicaid. J Surg Res 2023; 288:350-361. [PMID: 37060861 PMCID: PMC10192015 DOI: 10.1016/j.jss.2023.03.006] [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: 05/06/2022] [Revised: 12/21/2022] [Accepted: 03/08/2023] [Indexed: 04/17/2023]
Abstract
INTRODUCTION Population data on longitudinal trends for cholecystectomies and their outcomes are scarce. We evaluated the incidence and case fatality rate of emergency and ambulatory cholecystectomies in New Jersey (NJ) and whether the Medicaid expansion changed trends. MATERIALS AND METHODS A retrospective population cohort design was used to study the incidence of cholecystectomies and their case fatality rate from 2009 to 2018. Using linear and logistic regression we explored the trends of incidence and the odds of case fatality after versus before the January 1, 2014 Medicaid expansion. RESULTS Overall, 93,423 emergency cholecystectomies were performed, with 644 fatalities; 87,239 ambulatory cholecystectomies were performed, with fewer than 10 fatalities. The 2009 to 2018 annual incidence of emergency cholecystectomies dropped markedly from 114.8 to 77.5 per 100,000 NJ population (P < 0.0001); ambulatory cholecystectomies increased from 93.5 to 95.6 per 100,000 (P = 0.053). The incidence of emergency cholecystectomies dropped more after than before Medicaid expansion (P < 0.0001). The odds ratio for case fatality among those undergoing emergency cholecystectomies after versus before expansion was 0.85 (95% CI, 0.72-0.99). This decrease in case fatality, apparent only in those over age 65, was not explained by the addition of Medicaid. CONCLUSIONS A marked decrease in the incidence of emergency cholecystectomies occurred after Medicaid expansion, which was not accounted for by a minimal increase in the incidence of ambulatory cholecystectomies. Case fatality from emergency cholecystectomy decreased over time due to factors other than Medicaid. Further work is needed to reconcile these findings with the previously reported lack of decrease in overall gallstone disease mortality in NJ.
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Affiliation(s)
- Gregory L Peck
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey; New Jersey Alliance for Clinical and Translational Science, New Brunswick, New Jersey.
| | - Yen-Hong Kuo
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
| | - Shawna V Hudson
- New Jersey Alliance for Clinical and Translational Science, New Brunswick, New Jersey; Department of Family Practice, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey; Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Vicente H Gracias
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jason A Roy
- New Jersey Alliance for Clinical and Translational Science, New Brunswick, New Jersey; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
| | - Brian L Strom
- Rutgers Biomedical and Health Sciences, Newark, New Jersey
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Sekimitsu S, Elze T, Zebardast N. Impact of the Affordable Care Act on Glaucoma Severity at First Presentation. Ophthalmic Epidemiol 2023; 30:326-329. [PMID: 35723011 PMCID: PMC9763541 DOI: 10.1080/09286586.2022.2089357] [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: 03/03/2022] [Revised: 06/01/2022] [Accepted: 06/05/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To test whether the increase in insurance coverage in Massachusetts due to the Affordable Care Act (ACA) is associated with a decrease in glaucoma severity in patients presenting for the first time at a tertiary health system. METHODS Clinical and billing data of first-time glaucoma patients from a tertiary health system in Massachusetts from 2006 to 2021 was used. Pre-ACA is defined as before 2014 and post-ACA is defined as after 2014. Visual field mean deviation was used to define glaucoma severity: greater than -6 dB, less than -6 dB and greater than -12 dB, and less than -12 dB was classified as "mild," "moderate," and "severe" respectively. Ordinal logistic regression models adjusted for age, race, gender, and insurance type were used to determine the odds of presenting with more severe glaucoma. RESULTS 2,394 pre-ACA and 3,651 post-ACA first-time glaucoma patients were identified. There was no significant difference in the likelihood of more severe glaucoma at first presentation post-ACA compared to pre-ACA (OR=0.96; 95% CI 0.86-1.08; p=0.49) among the entire population. In stratified analyses, patients who utilized Medicaid for insurance had 52% decreased odds for presenting with more severe glaucoma at first presentation post-ACA compared to pre-ACA (OR=0.48; 95% CI 0.33-0.69; p<0.001). This remained significant after adjustment for age, race, and gender (adjusted OR=0.44; 95% CI 0.29-0.65; p<0.001). CONCLUSION At a Massachusetts-based tertiary healthcare center, individuals on Medicaid were more likely to have more severe glaucoma at first presentation before the implementation of the ACA, compared to after.
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Affiliation(s)
| | - Tobias Elze
- Schepens Eye Research Institute, Harvard Medical School, Boston, MA, USA
| | - Nazlee Zebardast
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
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HERD PAMELA. Improving Older Adults' Health by Reducing Administrative Burden. Milbank Q 2023; 101:507-531. [PMID: 37096624 PMCID: PMC10126975 DOI: 10.1111/1468-0009.12629] [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: 10/17/2022] [Revised: 11/30/2022] [Accepted: 01/24/2023] [Indexed: 04/26/2023] Open
Abstract
Policy Points Administrative burdens, which are the onerous experiences people have when trying to access government benefits and services, reduce older adult's access to health promoting policies. Although considerable attention has been focused on threats to the old-age welfare state, ranging from long-term financing problems to attempts to roll back benefits, administrative barriers to these programs already threaten their effectiveness. Reducing administrative burden is a viable way to improve population health among older adults going forward over the next decade.
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22
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Quasi-Experimental Design for Health Policy Research: A Methodology Overview. Plast Reconstr Surg 2023; 151:667-675. [PMID: 36730158 DOI: 10.1097/prs.0000000000009974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
SUMMARY Health policy impacts all aspects of the authors' field. Research on this topic informs future policy direction and serves as an impactful means to advocate for their patients. The present work aims to promote policy research in plastic surgery. To accomplish this goal, the authors discuss quasi-experimental research design. The authors include in-depth discussion regarding study techniques that are well suited to health policy, including interrupted time series, difference-in-differences analysis, regression discontinuity design, and instrumental variable design. For each study design, the authors discuss examples and potential limitations.
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Simon RC, Kim J, Schmidt S, Brimhall BB, Salazar CI, Wang CP, Wang Z, Sarwar ZU, Manuel LS, Damien P, Shireman PK. Association of Insurance Type With Inpatient Surgery 30-Day Complications and Costs. J Surg Res 2023; 282:22-33. [PMID: 36244224 DOI: 10.1016/j.jss.2022.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/10/2022] [Accepted: 09/15/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Safety-net hospitals (SNHs) have higher postoperative complications and costs versus low-burden hospitals. Do low socioeconomic status/vulnerable patients receive care at lower-quality hospitals or are there factors beyond providers' control? We studied the association of private, Medicare, and vulnerable insurance type with complications/costs in a high-burden SNH. METHODS Retrospective inpatient cohort study using National Surgical Quality Improvement Program (NSQIP) data (2013-2019) with cost data risk-adjusted by frailty, preoperative serious acute conditions (PASC), case status, and expanded operative stress score (OSS) to evaluate 30-day unplanned reoperations, any complication, Clavien-Dindo IV (CDIV) complications, and hospitalization variable costs. RESULTS Cases (Private 1517; Medicare 1224; Vulnerable 3648) with patient mean age 52.3 y [standard deviation = 14.7] and 47.3% male. Adjusting for frailty and OSS, vulnerable patients had higher odds of PASC (aOR = 1.71, CI = 1.39-2.10, P < 0.001) versus private. Adjusting for frailty, PASC and OSS, Medicare (aOR = 1.27, CI = 1.06-1.53, P = 0.009), and vulnerable (aOR = 2.44, CI = 2.13-2.79, P < 0.001) patients were more likely to undergo urgent/emergent surgeries. Vulnerable patients had increased odds of reoperation and any complications versus private. Variable cost percentage change was similar between private and vulnerable after adjusting for case status. Urgent/emergent case status increased percentage change costs by 32.31%. We simulated "switching" numbers of private (3648) versus vulnerable (1517) cases resulting in an estimated variable cost of $49.275 million, a 25.2% decrease from the original $65.859 million. CONCLUSIONS Increased presentation acuity (PASC and urgent/emergent surgeries) in vulnerable patients drive increased odds of complications and costs versus private, suggesting factors beyond providers' control. The greatest impact on outcomes may be from decreasing the incidence of urgent/emergent surgeries by improving access to care.
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Affiliation(s)
- Richard C Simon
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Bradley B Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, Texas; University Health, San Antonio, Texas
| | | | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Zhu Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Zaheer U Sarwar
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas; University Health, San Antonio, Texas
| | - Laura S Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Paul Damien
- Department of Information, Risk, and Operations Management, Red McCombs School of Business, University of Texas, Austin, Texas
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas; University Health, San Antonio, Texas; Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH.
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Tetley JC, Jacobs MA, Kim J, Schmidt S, Brimhall BB, Mika V, Wang CP, Manuel LS, Damien P, Shireman PK. Association of Insurance Type With Colorectal Surgery Outcomes and Costs at a Safety-Net Hospital: A Retrospective Observational Study. ANNALS OF SURGERY OPEN 2022; 3:e215. [PMID: 36590892 PMCID: PMC9780053 DOI: 10.1097/as9.0000000000000215] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/02/2022] [Indexed: 11/09/2022] Open
Abstract
Association of insurance type with colorectal surgical complications, textbook outcomes (TO), and cost in a safety-net hospital (SNH). Background SNHs have higher surgical complications and costs compared to low-burden hospitals. How does presentation acuity and insurance type influence colorectal surgical outcomes? Methods Retrospective cohort study using single-site National Surgical Quality Improvement Program (2013-2019) with cost data and risk-adjusted by frailty, preoperative serious acute conditions (PASC), case status and open versus laparoscopic to evaluate 30-day reoperations, any complication, Clavien-Dindo IV (CDIV) complications, TO, and hospitalization variable costs. Results Cases (Private 252; Medicare 207; Medicaid/Uninsured 619) with patient mean age 55.2 years (SD = 13.4) and 53.1% male. Adjusting for frailty, open abdomen, and urgent/emergent cases, Medicaid/Uninsured patients had higher odds of presenting with PASC (adjusted odds ratio [aOR] = 2.02, 95% confidence interval [CI] = 1.22-3.52, P = 0.009) versus Private. Medicaid/Uninsured (aOR = 1.80, 95% CI = 1.28-2.55, P < 0.001) patients were more likely to undergo urgent/emergent surgeries compared to Private. Medicare patients had increased odds of any and CDIV complications while Medicaid/Uninsured had increased odds of any complication, emergency department or observations stays, and readmissions versus Private. Medicare (aOR = 0.51, 95% CI = 0.33-0.88, P = 0.003) and Medicaid/Uninsured (aOR = 0.43, 95% CI = 0.30-0.60, P < 0.001) patients had lower odds of achieving TO versus Private. Variable cost %change increased in Medicaid/Uninsured patients to 13.94% (P = 0.005) versus Private but was similar after adjusting for case status. Urgent/emergent cases (43.23%, P < 0.001) and any complication (78.34%, P < 0.001) increased %change hospitalization costs. Conclusions Decreasing the incidence of urgent/emergent colorectal surgeries, possibly by improving access to care, could have a greater impact on improving clinical outcomes and decreasing costs, especially in Medicaid/Uninsured insurance type patients.
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Affiliation(s)
- Jasmine C. Tetley
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Michael A. Jacobs
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Jeongsoo Kim
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, TX
- University Health, San Antonio, TX
| | | | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX
| | - Paul Damien
- Department of Information, Risk, and Operations Management, Red McCombs School of Business, University of Texas, Austin, TX
| | - Paula K. Shireman
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
- University Health, San Antonio, TX
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, TX
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Yuskaitis CJ, Mytinger JR, Baumer FM, Zhang B, Liu S, Samanta D, Hussain SA, Yozawitz EG, Keator CG, Joshi C, Singh RK, Bhatia S, Bhalla S, Shellhaas R, Harini C. Association of Time to Clinical Remission With Sustained Resolution in Children With New-Onset Infantile Spasms. Neurology 2022; 99:e2494-e2503. [PMID: 36038267 PMCID: PMC9728034 DOI: 10.1212/wnl.0000000000201232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 07/27/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Standard therapies (adrenocorticotropic hormone [ACTH], oral steroids, or vigabatrin) fail to control infantile spasms in almost half of children. Early identification of nonresponders could enable rapid initiation of sequential therapy. We aimed to determine the time to clinical remission after appropriate infantile spasms treatment initiation and identify predictors of the time to infantile spasms treatment response. METHODS The National Infantile Spasms Consortium prospectively followed children aged 2-24 months with new-onset infantile spasms at 23 US centers (2012-2018). We included children treated with standard therapy (ACTH, oral steroids, or vigabatrin). Sustained treatment response was defined as having the last clinically recognized infantile spasms on or before treatment day 14, absence of hypsarrhythmia on EEG 2-4 weeks after treatment, and persistence of remission to day 30. We analyzed the time to treatment response and assessed clinical characteristics to predict sustained treatment response. RESULTS Among 395 infants, clinical infantile spasms remission occurred in 43% (n = 171) within the first 2 weeks of treatment, of which 81% (138/171) responded within the first week of treatment. There was no difference in the median time to response across standard therapies (ACTH: median 4 days, interquartile range [IQR] 3-7; oral steroids: median 3 days, IQR 2-5; vigabatrin: median 3 days, IQR 1-6). Individuals without hypsarrhythmia on the pretreatment EEG (i.e., abnormal but not hypsarrhythmia) were more likely to have early treatment response than infants with hypsarrhythmia at infantile spasms onset (hazard ratio 2.23, 95% CI 1.39-3.57). No other clinical factors predicted early responders to therapy. DISCUSSION Remission after first infantile spasms treatment can be identified by treatment day 7 in most children. Given the importance of early and effective treatment, these data suggest that children who do not respond to standard infantile spasms therapy within 1 week should be reassessed immediately for additional standard treatment. This approach could optimize outcomes by facilitating early sequential therapy for children with infantile spasms.
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Affiliation(s)
- Christopher J Yuskaitis
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI.
| | - John R Mytinger
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Fiona M Baumer
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Bo Zhang
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Shanshan Liu
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Debopam Samanta
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Shaun A Hussain
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Elissa G Yozawitz
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Cynthia G Keator
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Charuta Joshi
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Rani K Singh
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Sonal Bhatia
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Sonam Bhalla
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Renée Shellhaas
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Chellamani Harini
- From the Division of Epilepsy and Clinical Neurophysiology (C.J.Y., C.H.), Department of Neurology, Boston Children's Hospital, MA; Department of Pediatrics (J.R.M.), Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus; Division of Child Neurology (F.M.B.), Department of Neurology, Stanford University School of Medicine, Palo Alto, CA; Department of Neurology and ICCTR Biostatistics and Research Design Center (B.Z., S.L.), Boston Children's Hospital and Harvard Medical School, MA; Division of Child Neurology (D.S.), Department of Pediatrics, University of Arkansas for Medical Sciences, AR; Department of Pediatrics (S.A.H.), Division of Neurology, University of California, Los Angeles; Department of Neurology (E.G.Y.), Montefiore Medical Center, Bronx, NY; Jane and John Justin Neurosciences (C.G.K.), Cook Children's Hospital, Fort Worth, TX; Departments of Pediatrics and Neurology (C.J.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; Department of Pediatrics (R.K.S.), Division of Neurology, Atrium Health/Levine Children's, Charlotte, NC; Division of Pediatric Neurology (S. Bhatia), Department of Pediatrics, Medical University of South Carolina, Charleston; Department of Pediatrics (S. Bhalla), Division of Child Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA; and Department of Pediatrics (R.S.), Michigan Medicine, University of Michigan, Ann Arbor, MI
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Ramadan OI, Santos T, Stoecker JB, Belkin N, Jackson BM, Schneider DB, Rice J, Wang GJ. The Differential Impact of Medicaid Expansion on Disparities in Outcomes Following Peripheral Vascular Intervention. Ann Vasc Surg 2022; 86:135-143. [PMID: 35460861 DOI: 10.1016/j.avsg.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Peripheral artery disease (PAD) disproportionately affects nonwhite, Hispanic/Latino, and low socioeconomic status patients, who are less likely to have insurance and routine healthcare visits. Medicaid expansion (ME) has improved insurance rates and access to care, potentially benefitting these patients. We sought to assess the impact of ME on disparities in outcomes after peripheral vascular intervention (PVI) for PAD. METHODS A retrospective analysis of prospectively-collected Vascular Quality Initiative PVI procedures between 2011 and 2019 was conducted. The sample was restricted to first-record procedures in adults under the age 65 in states that expanded Medicaid on January 1, 2014 (ME group) or had not expanded before January 1, 2019 (non-expansion [NE] group). ME and NE groups were compared between pre-expansion (2011-2013) and post-expansion (2014- 2019) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors and clinical center and year fixed effects. Our primary outcome was 1-year major amputation. Secondary outcomes included trends in presentation, 30-day mortality, 1-year mortality, and 1-year primary and secondary patency. Outcomes were stratified by race and ethnicity. RESULTS We examined 34,313 PVI procedures, including 20,378 with follow-up data. Rates of Medicaid insurance increased post-expansion in ME and NE states (ME 16.7% to 23.0%, P < 0.001; NE 10.0% to 11.9%, P = 0.013) while rates of self-pay decreased in ME states only (ME 4.6% to 1.8%, P < 0.001; NE 8.1% to 8.4%, P = 0.620). Adjusted difference-in-differences analysis revealed lower odds of urgent/emergent PVI among all patients and all nonwhite patients in ME states post-expansion compared to NE states (all: odds ratio [OR] 0.53 [95% confidence interval 0.33-0.87], P = 0.011; nonwhite: OR 0.41 [0.19-0.88], P = 0.023). No differences were observed for 1-year major amputation (OR 0.70 [0.43-1.14], P = 0.152), primary patency (OR 0.93 [0.63-1.38], P = 0.726), or secondary patency (OR 1.29 [0.69-2.41], P = 0.431). Odds of 1-year mortality were higher in ME states post-expansion compared to NE states (OR 2.50 [1.07-5.87], P = 0.035), although 30-day mortality was not different (OR 2.04 [0.60-6.90], P = 0.253). Notably, odds of 1-year major amputation among Hispanic/Latino patients decreased in ME states post-expansion compared to NE states (OR 0.11 [0.01-0.86], P = 0.036). CONCLUSIONS ME was associated with lower odds of 1-year major amputation among Hispanic/Latino patients who underwent PVI for PAD. ME was also associated with lower odds of urgent/emergent procedures among patients overall and nonwhite patients specifically. However, 1-year mortality increased in the overall cohort. Further study is needed to corroborate our findings that ME may have benefits for certain underserved populations with PAD.
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Affiliation(s)
- Omar I Ramadan
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Tatiane Santos
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; The Wharton School at the University of Pennsylvania, Philadelphia, PA
| | - Jordan B Stoecker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Nathan Belkin
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Benjamin M Jackson
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Darren B Schneider
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jayne Rice
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Pain D, Takvorian SU, Narayan V. Disparities in Clinical Care and Research in Renal Cell Carcinoma. KIDNEY CANCER 2022. [DOI: 10.3233/kca-220006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Disparities in cancer screening, prevention, therapy, clinical outcomes, and research are increasingly recognized and pervade all malignancies. In response, several cancer research and clinical care organizations have issued policy statements to acknowledge and address barriers to achieving health equity in cancer care. The increasingly specialized nature of oncology warrants a disease-focused appraisal of existing disparities and potential solutions. Although clear improvements in clinical outcomes have been recently observed for patients with renal cell carcinoma (RCC), these improvements have not been equally shared across diverse populations. This review describes existing RCC cancer disparities and their potential contributing factors and discusses opportunities to improve health equity in clinical research for all patients with RCC.
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Affiliation(s)
- Debanjan Pain
- Division of Hematology/Medical Oncology, University of Pennsylvania, Abramson Cancer Center, Philadelphia, PA, USA
| | - Samuel U. Takvorian
- Division of Hematology/Medical Oncology, University of Pennsylvania, Abramson Cancer Center, Philadelphia, PA, USA
| | - Vivek Narayan
- Division of Hematology/Medical Oncology, University of Pennsylvania, Abramson Cancer Center, Philadelphia, PA, USA
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Glance LG, Dick AW, Shippey E, McCormick PJ, Dutton R, Stone PW, Shang J, Lustik SJ, Lander HL, Gosev I, Joynt Maddox KE. Association Between the COVID-19 Pandemic and Insurance-Based Disparities in Mortality After Major Surgery Among US Adults. JAMA Netw Open 2022; 5:e2222360. [PMID: 35849395 PMCID: PMC9294995 DOI: 10.1001/jamanetworkopen.2022.22360] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE The COVID-19 pandemic caused significant disruptions in surgical care. Whether these disruptions disproportionately impacted economically disadvantaged individuals is unknown. OBJECTIVE To evaluate the association between the COVID-19 pandemic and mortality after major surgery among patients with Medicaid insurance or without insurance compared with patients with commercial insurance. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the Vizient Clinical Database for patients who underwent major surgery at hospitals in the US between January 1, 2018, and May 31, 2020. EXPOSURES The hospital proportion of patients with COVID-19 during the first wave of COVID-19 cases between March 1 and May 31, 2020, stratified as low (≤5.0%), medium (5.1%-10.0%), high (10.1%-25.0%), and very high (>25.0%). MAIN OUTCOMES AND MEASURES The main outcome was inpatient mortality. The association between mortality after surgery and payer status as a function of the proportion of hospitalized patients with COVID-19 was evaluated with a quasi-experimental triple-difference approach using logistic regression. RESULTS Among 2 950 147 adults undergoing inpatient surgery (1 550 752 female [52.6%]) at 677 hospitals, the primary payer was Medicare (1 427 791 [48.4%]), followed by commercial insurance (1 000 068 [33.9%]), Medicaid (321 600 [10.9%]), other payer (140 959 [4.8%]), and no insurance (59 729 [2.0%]). Mortality rates increased more for patients undergoing surgery during the first wave of the pandemic in hospitals with a high COVID-19 burden (adjusted odds ratio [AOR], 1.13; 95% CI, 1.03-1.24; P = .01) and a very high COVID-19 burden (AOR, 1.38; 95% CI, 1.24-1.53; P < .001) compared with patients in hospitals with a low COVID-19 burden. Overall, patients with Medicaid had 29% higher odds of death (AOR, 1.29; 95% CI, 1.22-1.36; P < .001) and patients without insurance had 75% higher odds of death (AOR, 1.75; 95% CI, 1.55-1.98; P < .001) compared with patients with commercial insurance. However, mortality rates for surgical patients with Medicaid insurance (AOR, 1.03; 95% CI, 0.82-1.30; P = .79) or without insurance (AOR, 0.85; 95% CI, 0.47-1.54; P = .60) did not increase more than for patients with commercial insurance in hospitals with a high COVID-19 burden compared with hospitals with a low COVID-19 burden. These findings were similar in hospitals with very high COVID-19 burdens. CONCLUSIONS AND RELEVANCE In this cross-sectional study, the first wave of the COVID-19 pandemic was associated with a higher risk of mortality after surgery in hospitals with more than 25.0% of patients with COVID-19. However, the pandemic was not associated with greater increases in mortality among patients with no insurance or patients with Medicaid compared with patients with commercial insurance in hospitals with a very high COVID-19 burden.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| | | | - Ernie Shippey
- Vizient Center for Advanced Analytics, Chicago, Illinois
| | | | | | - Patricia W. Stone
- Center for Health Policy, Columbia School of Nursing, New York, New York
| | - Jingjing Shang
- Center for Health Policy, Columbia School of Nursing, New York, New York
| | - Stewart J. Lustik
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Heather L. Lander
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Igor Gosev
- Department of Surgery, University of Rochester School of Medicine, Rochester, New York
| | - Karen E. Joynt Maddox
- Department of Medicine, Washington University in St Louis, Missouri
- Center for Health Economics and Policy at the Institute for Public Health, Washington University in St Louis, Missouri
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Schroeder TE, Samson KK, Kerns E, Berrondo C. Impact of Healthcare Disparities on Time to Surgery for Pediatric Urologic Patients. Cureus 2022; 14:e25711. [PMID: 35836442 PMCID: PMC9275528 DOI: 10.7759/cureus.25711] [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: 06/07/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Healthcare disparities are differences in health outcomes reflecting social inequalities. We aim to identify healthcare disparities in pediatric urologic patients by analyzing the time from surgical scheduling to completion of procedure at a single center and identify variables associated with increased time to surgery. Materials and methods We reviewed all patients aged 0-18 years who underwent surgery with one of three pediatric urologists at our institution from January 1, 2018, to December 31, 2019. We collected or calculated variables including age, sex, race, ethnicity, caregivers’ primary language, insurance status, zip code, median distance to hospital, clinic visit date, and time to surgery (calculated as days between surgery request and date of surgery). Data analysis included bivariate analysis and linear regression with all variables of interest presented with 95% confidence intervals (CIs), where log-transformed time to surgery was the outcome. Because the practice at our institution is to delay elective surgeries until after six months of age, we excluded patients who were less than six months of age at the time of surgery request date. Results A total of 697 patients were included in the final analysis. Patients’ caregivers who spoke languages other than English or Spanish had a lower model-adjusted mean log-days to surgery (−0.44; 95% CI: −0.85, −0.03) relative to English-speaking caregivers. Uninsured patients had increased time to surgery compared to Medicaid patients (0.28; 95% CI: 0.03, 0.53). Income was also associated with increased time to surgery, meaning patients from higher-income backgrounds had a longer time to surgery (0.04; 95% CI: 0.00, 0.08). Conclusions In our patient population, primary language spoken and insurance status were associated with increases in time from initial evaluation to surgical intervention among pediatric patients undergoing urologic surgery. Additional research is needed to better understand variations in access to pediatric urologic surgery.
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Glance LG, Chandrasekar EK, Shippey E, Stone PW, Dutton R, McCormick PJ, Shang J, Lustik SJ, Wu IY, Eaton MP, Dick AW. Association Between the COVID-19 Pandemic and Disparities in Access to Major Surgery in the US. JAMA Netw Open 2022; 5:e2213527. [PMID: 35604684 PMCID: PMC9127559 DOI: 10.1001/jamanetworkopen.2022.13527] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Racial minority groups account for 70% of excess deaths not related to COVID-19. Understanding the association of the Centers for Medicare & Medicaid Services' (CMS's) moratorium delaying nonessential operations with racial disparities will help shape future pandemic responses. OBJECTIVE To evaluate the association of the CMS's moratorium on elective operations during the first wave of the COVID-19 pandemic among Black individuals, Asian individuals, and individuals of other races compared with White individuals. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study assessed a 719-hospital retrospective cohort of 3 470 905 adult inpatient hospitalizations for major surgery between January 1, 2018, and October 31, 2020. EXPOSURE The first wave of COVID-19 infections between March 1, 2020, and May 31, 2020. MAIN OUTCOMES AND MEASURES The main outcome was the association between changes in monthly elective surgical case volumes and the first wave of COVID-19 infections as a function of patient race, evaluated using negative binomial regression analysis. RESULTS Among 3 470 905 adults (1 823 816 female [52.5%]) with inpatient hospitalizations for major surgery, 70 752 (2.0%) were Asian, 453 428 (13.1%) were Black, 2 696 929 (77.7%) were White, and 249 796 (7.2%) were individuals of other races. The number of monthly elective cases during the first wave was 49% (incident rate ratio [IRR], 0.49; 95% CI, 0.486-0.492; P < .001) compared with the baseline period. The relative reduction in unadjusted elective surgery cases for Black (unadjusted IRR, 0.99; 95% CI, 0.97-1.01; P = .36), Asian (unadjusted IRR, 1.08; 95% CI, 1.03-1.14; P = .001), and other race individuals (unadjusted IRR, 0.97; 95% CI, 0.95-1.00; P = .05) during the surge period compared with the baseline period was very close to the change in cases for White individuals. After adjustment for age, sex, comorbidities, and surgical procedure, there was still no evidence that the first wave of the pandemic was associated with disparities in access to elective surgery. CONCLUSIONS AND RELEVANCE In this cross-sectional study, the CMS's moratorium on nonessential operations was associated with a 51% reduction in elective operations. It was not associated with greater reductions in operations for racial minority individuals than for White individuals. This evidence suggests that the early response to the pandemic did not increase disparities in access to surgical care.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| | - Eeshwar K. Chandrasekar
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Ernie Shippey
- Vizient Center for Advanced Analytics, Chicago, Illinois
| | - Patricia W. Stone
- Columbia School of Nursing, Center for Health Policy, New York, New York
| | | | | | - Jingjing Shang
- Columbia School of Nursing, Center for Health Policy, New York, New York
| | - Stewart J. Lustik
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Isaac Y. Wu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Michael P. Eaton
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
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Emanuelson RD, Brown SJ, Termuhlen PM. Interhospital Transfer (IHT) in Emergency General Surgery Patients (EGS): A Scoping Review. Surg Open Sci 2022; 9:69-79. [PMID: 35706931 PMCID: PMC9190042 DOI: 10.1016/j.sopen.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 05/14/2022] [Indexed: 11/26/2022] Open
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Bouchard ME, Kwon S, Many BT, Vacek JC, Abdullah F, Ghomrawi H. Impact of the Affordable Care Act's Medicaid expansion on tertiary pediatric surgical care. J Pediatr Surg 2022; 57:502-508. [PMID: 34034883 DOI: 10.1016/j.jpedsurg.2021.04.012] [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: 02/04/2021] [Revised: 03/27/2021] [Accepted: 04/10/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Many children gained insurance with the 2014 Affordable Care Act's (ACA) Medicaid Expansion (ME), yet its impact on access to pediatric tertiary surgical care remains unknown. We examined the effect of ME on rates of elective, ambulatory surgery (EAS), especially among publicly-insured and ethnoracial-minority patients. METHODS Surgical patients ≤18 years between 2012 and 2018 were identified using the Pediatric Health Information System. Interrupted time series analyses were conducted to predict the monthly proportion of publicly-insured patients and EAS rates in ME and nonexpansion states. RESULTS 3,270,842 patients were included. Nonexpansion states demonstrated a 1.10% (p<0.05) increase in the proportion of publicly-insured patients at ACA implementation, which then plateaued. No immediate change was observed in ME states, but there was an annual 1.08% (p<0.01) decrease in subsequent years. Publicly-insured EAS rates decreased by 1.09% (p<0.01) in nonexpansion states; no change was observed in ME states. A 3.36% (p<0.01) increase in EAS rates was observed in nonexpansion and ME states. The gap in EAS rates increased between private and publicly-insured patients in nonexpansion, but not ME states. CONCLUSIONS Increased coverage for children in ME states was not associated with more access to tertiary pediatric surgical care; however, while nonexpansion states saw an increase in insurance-based disparities, ME states did not. Though insurance coverage is critical to access, other factors may be contributing to persistent disparities in access to pediatric surgical care.
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Affiliation(s)
- Megan E Bouchard
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Soyang Kwon
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Benjamin T Many
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jonathan C Vacek
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Fizan Abdullah
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Hassan Ghomrawi
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.
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Gatto AP, Feeley BT, Lansdown DA. Low socioeconomic status worsens access to care and outcomes for rotator cuff repair: a scoping review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:26-34. [PMID: 37588282 PMCID: PMC10426503 DOI: 10.1016/j.xrrt.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Poor socioeconomic status (SES) is consistently associated with poor quality of health care, particularly in the field of orthopedics. Expanding insurance coverage has created a larger patient population by specifically making health care more accessible, translating to greater demand for care in the low-SES population. The purpose of this article is to provide a scoping review of literature observing access and outcomes of rotator cuff repair surgery among low-SES populations. Methods We performed a systematic review of articles using PubMed, Embase, and EBSCO (May 2021) from 2010 onward. Peer-reviewed articles that recorded at least one SES measure specific to patients who underwent rotator cuff repair from the United States were included. SES measures were methodically defined as income, occupation, employment, education, and race. All data that aligned with these SES measures were extracted. Results Of the 1009 titles reviewed, 109 studies were screened by abstract, 23 were reviewed in full, and 7 studies met criteria for inclusion. Of the 5 studies investigating access, all 5 found disparities among postoperative physical therapy, orthopedic consult, and surgery, using Medicaid status as a proxy for income in addition to other income measures. Of the 3 studies analyzing outcomes, 2 found that low-SES patients had worse pain and function, again based on Medicaid status and other income measures. Education did not have a significant impact on outcomes, as per the 1 study that included it. No studies included measures of occupation or employment. Conclusion Patients of low SES face reduced access to cuff repair care and worse associated outcomes, despite federal and state government efforts to reduce health care disparity through health care reform. The small nature of this review reflects how measures of SES are often not examined in rotator cuff repair studies.
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Affiliation(s)
- Andrew P. Gatto
- Touro University California, College of Osteopathic Medicine, Vallejo, CA, USA
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Brian T. Feeley
- Touro University California, College of Osteopathic Medicine, Vallejo, CA, USA
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Drew A. Lansdown
- Touro University California, College of Osteopathic Medicine, Vallejo, CA, USA
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
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Ayubcha C, Pouladvand P, Ayubcha S. A Quasi-Experimental Study of Medicaid Expansion and Urban Mortality in the American Northeast. Front Public Health 2021; 9:707907. [PMID: 34869142 PMCID: PMC8637894 DOI: 10.3389/fpubh.2021.707907] [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: 10/05/2021] [Accepted: 10/08/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: To investigate the association of state-level Medicaid expansion and non-elderly mortality rates from 1999 to 2018 in Northeastern urban settings. Methods: This quasi-experimental study utilized a synthetic control method to assess the association of Medicaid expansion on non-elderly urban mortality rates [1999–2018]. Counties encompassing the largest cities in the Northeastern Megalopolis (Washington D.C., Baltimore, Philadelphia, New York City, and Boston) were selected as treatment units (n = 5 cities, 3,543,302 individuals in 2018). Cities in states without Medicaid expansion were utilized as control units (n = 17 cities, 12,713,768 individuals in 2018). Results: Across all cities, there was a significant reduction in the neoplasm (Population-Adjusted Average Treatment Effect = −1.37 [95% CI −2.73, −0.42]) and all-cause (Population-Adjusted Average Treatment Effect = −2.57 [95%CI −8.46, −0.58]) mortality rate. Washington D.C. encountered the largest reductions in mortality (Average Treatment Effect on All-Cause Medical Mortality = −5.40 monthly deaths per 100,000 individuals [95% CI −12.50, −3.34], −18.84% [95% CI −43.64%, −11.67%] reduction, p = < 0.001; Average Treatment Effect on Neoplasm Mortality = −1.95 monthly deaths per 100,000 individuals [95% CI −3.04, −0.98], −21.88% [95% CI −34.10%, −10.99%] reduction, p = 0.002). Reductions in all-cause medical mortality and neoplasm mortality rates were similarly observed in other cities. Conclusion: Significant reductions in urban mortality rates were associated with Medicaid expansion. Our study suggests that Medicaid expansion saved lives in the observed urban settings.
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Affiliation(s)
| | - Pedram Pouladvand
- Alfred I. DuPont Hospital for Children, Wilmington, NC, United States
| | - Soussan Ayubcha
- Marcus Institute of Integrative Health, Thomas Jefferson University, Philadelphia, PA, United States
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Cohen BD, Zeymo A, Bouchard M, McDermott J, Shara NM, Sellke FW, Sodha N, Al-Refaie WB, Ehsan A. Increased Access to Cardiac Surgery Did Not Improve Outcomes: Early Look into Medicaid Expansion. Ann Thorac Surg 2021; 114:1637-1644. [PMID: 34678282 DOI: 10.1016/j.athoracsur.2021.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 08/02/2021] [Accepted: 09/04/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cardiac surgery utilization has increased after passage of the Affordable Care Act. This multi-state study examined whether changes in access after Medicaid Expansion (ME) have led to improved outcomes, overall and particularly among ethno-racial minorities. METHODS State Inpatient Databases were used to identify non-elderly adults (ages 18-64) who underwent coronary artery bypass grafting, aortic valve replacement, mitral valve replacement, or mitral valve repair in three expansion (Kentucky, New Jersey, Maryland) vs two non-expansion states (North Carolina, Florida) from 2012 to 2015. Linear and logistic Interrupted Time Series (ITS) were used with two-way interactions and adjusted for patient, hospital, and county-level factors to compare trends and instantaneous changes at the point of ME implementation (Q1 2014) for mortality, length of stay (LOS), and elective status. ITS models estimated expansion effect, overall and by race-ethnicity. RESULTS Analysis included 22,038 cardiac surgery patients from expansion states and 33,190 from non-expansion states. In expansion states, no significant trend changes were observed for mortality (OR 1.01, p=0.83) or LOS (β= -0.05, p=0.20), or elective surgery (OR 1.00, p=0.91). There were similar changes seen in non-expansion states. Among ethno-racial minorities, ME did not impact outcomes or elective status. CONCLUSIONS Despite an increase in cardiac surgery utilization following ME, outcomes remained unchanged in the early period after implementation, overall and among ethno-racial minorities. Future research is needed to confirm long-term trends and examine reasons behind this lack of improved outcomes.
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Affiliation(s)
- Brian D Cohen
- MedStar-Georgetown University Medical Center, Department of Surgery, Washington, DC; MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Alexander Zeymo
- MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Megan Bouchard
- MedStar-Georgetown University Medical Center, Department of Surgery, Washington, DC; MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - James McDermott
- MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Nawar M Shara
- MedStar Health Research Institute, Washington, DC; Georgetown-Howard Universities, Center for Clinical and Translational Science, Washington, DC
| | - Frank W Sellke
- Brown University Medical School/Rhode Island Hospital, Division of Cardiothoracic Surgery, Providence, RI
| | - Neel Sodha
- Brown University Medical School/Rhode Island Hospital, Division of Cardiothoracic Surgery, Providence, RI
| | - Waddah B Al-Refaie
- MedStar-Georgetown University Medical Center, Department of Surgery, Washington, DC; MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC.
| | - Afshin Ehsan
- Brown University Medical School/Rhode Island Hospital, Division of Cardiothoracic Surgery, Providence, RI
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Haimovich JS, Cui J, Yeh RW, Ferris TG, Hsu J, Wasfy JH. Expansion of insurance under the affordable care act and invasive management of acute myocardial infarction. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 39:90-96. [PMID: 34756520 DOI: 10.1016/j.carrev.2021.10.003] [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: 09/21/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The Affordable Care Act of 2010 extended health insurance through expansion of Medicaid and subsidies for commercial insurance. Prior work has produced differing results in associating expanded insurance with improvements in health care processes and outcomes. Evaluating specific mechanisms of care processes and their association with insurance expansion may help reconcile those results. METHODS AND RESULTS We used inpatient hospitalization data in the Nationwide Inpatient Sample (NIS) Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality from 1/1/2008 to 9/30/2015. We included all hospitalizations for acute myocardial infarction (AMI). As a primary outcome, we defined percent rate of AMI hospitalizations receiving percutaneous coronary intervention (PCI) per month. In the non-Medicare (intervention) group, there was a relative decrease of 0.2% of the monthly trend before and after expansion (95% CI [-0.3%, -0.1%]). In the Medicare group, there was a relative decrease of 0.1% of the monthly trend before and after expansion (95% CI [-0.2%, 0%]). CONCLUSIONS We did not detect a relative difference in PCI for AMI associated with insurance expansion under health reform.
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Affiliation(s)
- Julian S Haimovich
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jinghan Cui
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert W Yeh
- Department of Medicine, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Timothy G Ferris
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Massachusetts General Physicians Organization, Boston, MA, USA
| | - John Hsu
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Massachusetts General Physicians Organization, Boston, MA, USA.
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Yesantharao PS, He W, Shetty P, Aravind P, Quan A, Fadavi D, Aliu O. The Impact of Policy Reform on Utilization of Popular Reconstructive Procedures. Ann Plast Surg 2021; 87:e40-e50. [PMID: 33346555 DOI: 10.1097/sap.0000000000002608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Medicaid beneficiaries systematically face challenges in accessing healthcare, especially with regard to specialty services like reconstructive surgery. This study evaluated the impact of 2 healthcare reform policies, Medicaid expansion and global hospital budgeting, on utilization of reconstructive surgery by Medicaid patients. METHODS Utilization of reconstructive surgery by Medicaid patients in New Jersey (Medicaid expansion/no global budget), Maryland (Medicaid expansion/with global budgets), and Florida (no Medicaid expansion/no global budget) between 2012 and 2016 was compared using quasi-experimental, interrupted time-series modeling. Subgroup analyses by procedure type and urgency were also undertaken. RESULTS During the study period, the likelihood of Medicaid patients using reconstructive surgery significantly increased in expansion states (Maryland: 0.3% [95% confidence interval = 0.17% to 0.42%] increase per quarter, P < 0.001; New Jersey: 0.4% [0.31% to 0.52%] increase per quarter, P = 0.004) when compared with Florida (nonexpansion state). Global budgeting did not significantly impact overall utilization of reconstructive procedures by Medicaid beneficiaries. Upon subgroup analyses, there was a greater increase in utilization of elective procedures than emergent procedures by Medicaid beneficiaries after Medicaid expansion (elective: 0.9% [0.8% to 1.3%] increase per quarter, P = 0.04; emergent/urgent: 0.2% [0.1% to 0.4%] increase per quarter, P = 0.02). In addition, Medicaid expansion had the greatest absolute effect on breast reconstruction (1.0% [95% confidence interval = 0.7% to 1.3%] increase per quarter) compared with other procedure types. CONCLUSIONS Medicaid expansion increased access to reconstructive surgery for Medicaid beneficiaries, especially for elective procedures. Encouragingly, although cost-constrictive, global hospital budgeting did not limit longitudinal utilization of reconstructive surgery by Medicaid patients, who are traditionally at higher risk for complications/readmissions.
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Affiliation(s)
- Pooja S Yesantharao
- From the Department of Plastic & Reconstructive Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD
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Loehrer AP, Leech MM, Weiss JE, Markey C, Wengle E, Aarons J, Zuckerman S. Association of Cost Sharing With Delayed and Complicated Presentation of Acute Appendicitis or Diverticulitis. JAMA HEALTH FORUM 2021; 2:e212324. [PMID: 35977177 PMCID: PMC8796960 DOI: 10.1001/jamahealthforum.2021.2324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/01/2021] [Indexed: 01/17/2023] Open
Abstract
Question Does an association exist between high cost-sharing insurance plans and patient presentation with and surgical management of acute appendicitis or acute diverticulitis? Findings In this cohort study of 151 852 patients, higher patient cost sharing was associated with lower odds of presenting with early, uncomplicated disease, receiving optimal surgical care, and receiving minimally invasive surgery. Meaning Policymakers should be aware of the clinical and financial implications of patient health care behaviors associated with increased cost sharing. Importance Treatment delays are associated with increased morbidity and cost of disease, although the extent to which cost sharing influences timely presentation and management of acute surgical disease remains unknown. Given recent policy changes using cost sharing to modify health care behavior, this study examines the association of cost sharing with the health of the patient at presentation and with receipt of optimal or minimally invasive surgery. Objective To assess whether cost sharing is associated with the likelihood of early, uncomplicated patient presentation or with surgical management of 2 representative emergency general surgery diagnoses: acute appendicitis and acute diverticulitis. Design, Setting, and Participants This cohort study used Health Care Cost Institute claims from January 1, 2013, through December 31, 2017, to analyze data of commercially insured individuals hospitalized for acute appendicitis or diverticulitis. In total, 151 852 patients in the data set aged 18 to 64 years and presenting with acute appendicitis or diverticulitis were included as identified using the International Classification of Diseases, Ninth Revision and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Data were analyzed from January 2020 through February 2021. Exposures The primary exposure was patient total cost sharing incurred for the index hospitalization, defined as their summed deductible, copayments, and coinsurance. Main Outcomes and Measures The primary outcome was early, uncomplicated disease presentation. Secondary outcomes were receipt of optimal surgical care and minimally invasive surgery if undergoing an operation. Analyses were conducted with multivariable logistic regression models to adjust for patient characteristics and community-level socioeconomic and geographic factors. High cost sharing was defined as quartile 4 (>$3082), and low cost sharing as quartile 1 ($0-$502). Results Among 151 852 patients, 52.4% were men, and the total cost-sharing median was $1725 (interquartile range, $503-$3082). Higher cost sharing was associated with lower odds of early, uncomplicated disease presentation (odds ratio, 0.63; 95% CI, 0.61-0.65). Patients with higher cost sharing were less likely to receive optimal surgical care (odds ratio, 0.96; 95% CI, 0.93-0.99) or minimally invasive surgery (odds ratio, 0.89; 95% CI, 0.84-0.95). Conclusions and Relevance The findings of this cohort study suggest that, as policymakers debate the degree of cost sharing in public and private insurance plans, attention should be given to the clinical and financial implications associated with care delays.
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Affiliation(s)
- Andrew P. Loehrer
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Mary M. Leech
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Julie E. Weiss
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Chad Markey
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Huynh KA, Jayaram M, Wang C, Lane M, Wang L, Momoh AO, Chung KC. Factors Associated With State-Specific Medicaid Expansion and Receipt of Autologous Breast Reconstruction Among Patients Undergoing Mastectomy. JAMA Netw Open 2021; 4:e2119141. [PMID: 34342650 PMCID: PMC8335577 DOI: 10.1001/jamanetworkopen.2021.19141] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Despite demonstrated psychosocial benefits, autologous breast reconstruction remains underutilized. An analysis of the association between Medicaid expansion and autologous breast reconstruction has yet to be performed. OBJECTIVE To compare autologous breast reconstruction rates and determine the association between Medicaid expansion and breast reconstruction. DESIGN, SETTING, AND PARTICIPANTS A retrospective cross-sectional study was performed using the State Inpatient Database from January 1, 2012, through September 30, 2015, and included 51 340 patients. Patients were identified using the International Classification of Diseases, Ninth Revision, codes for breast cancer, mastectomy, and autologous breast reconstruction. Data from states that expanded Medicaid (New Jersey, New York, and Washington) were compared with states that did not expand Medicaid (Florida, North Carolina, and Wisconsin). Data were analyzed from June 1, 2020, through February 28, 2021. EXPOSURES The Patient Protection and Affordable Care Act's Medicaid expansion was implemented in 2014; the preexpansion period ranged from 2012 to 2013 (2 years), whereas the postexpansion period ranged from 2014 to 2015 quarter 3 (1.75 years). MAIN OUTCOMES AND MEASURES Primary outcomes included use of autologous breast reconstruction before and after expansion. Independent covariates included patient demographics, comorbidities, and state of residence. RESULTS Among 45 850 patients who underwent mastectomy and 9215 patients who received autologous breast reconstruction, 36 777 (67%) were White and 32 205 (59%) had private insurance. The use of immediate or delayed autologous reconstruction increased from 18.1% (4951 of 27 290) to 23.0% (4264 of 18 560) throughout the study period. Compared with 2012, the odds of reconstruction were 64% higher in 2015 (odds ratio [OR], 1.64; 95% CI, 1.48-1.80; P < .001). African American (OR, 1.43; 95% CI, 1.33-1.55; P < .001) and Hispanic (OR, 1.44; 95% CI, 1.31-1.60; P < .001) patients had higher odds of reconstruction compared with White patients regardless of state of residence. However, Medicaid expansion was associated with a 28% decrease in the odds of reconstruction (OR, 0.72; 95% CI, 0.61-0.87; P < .001) for African American patients, a 40% decrease (OR, 0.60; 95% CI, 0.50-0.74; P < .001) for Hispanic patients, and 20% decrease (OR, 0.80; 95% CI, 0.67-0.96; P = .01) for patients with Asian, Native American, or other minority race/ethnicity. Medicaid expansion was not associated with changes in the odds of reconstruction for White patients. CONCLUSIONS AND RELEVANCE In this cross-sectional study, although the odds of receiving autologous breast reconstruction increased annually, Medicaid expansion was associated with decreased odds of reconstruction for African American patients, Hispanic patients, and other patients of color.
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Affiliation(s)
- Kristine A. Huynh
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Mayank Jayaram
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Chang Wang
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Megan Lane
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Lu Wang
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Adeyiza O. Momoh
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
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The impact of the affordable care act on surgeon selection amongst colorectal surgery patients. Am J Surg 2021; 222:256-261. [DOI: 10.1016/j.amjsurg.2021.01.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 01/19/2021] [Accepted: 01/31/2021] [Indexed: 12/13/2022]
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Abstract
BACKGROUND Traumatic injuries are significant sources of morbidity and mortality in the pediatric population. Using a national database, this study aims to characterize pediatric facial fracture management and the effect of health care policy changes on populations receiving treatment. METHODS A retrospective cohort study was performed using Healthcare Cost and Utilization Project Kids' Inpatient Database databases from 2000 to 2016. Pediatric patients admitted with a facial fracture diagnosis were included. Clinical outcomes include mortality, reduction of fracture during hospital stay, and open fracture reduction. The impact of the Affordable Care Act on patient demographics and management was assessed. RESULTS Between 2000 and 2016, 82,414 patients were managed for facial fractures, 8.3 percent of whom were managed after implementation of the Affordable Care Act (n = 6841). Mean age was 15.2 years, and the male-to-female ratio was 2.9:1. Significant racial disparities were identified before the Affordable Care Act: African American and Native American patients had decreased odds of having facial fracture reduction during the initial hospital stay (OR, 0.84 and 0.86, respectively), and identifying as either Hispanic or Native American was associated with higher odds of mortality (OR, 1.4 or 2.4, respectively). Race was not contributory to patient mortality after the Affordable Care Act. Before Affordable Care Act implementation, patients receiving care with no charge (including charity care/charity research) had lower odds of having an open reduction or any reduction; insurance status was not contributory to management after the Affordable Care Act. CONCLUSION Although the Affordable Care Act may have increased access to care for certain populations, race- and sex-associated differences in mortality rate and fracture management should be further investigated to ensure a national standard of equitable patient care.
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Improving clinical documentation of evaluation and management care and patient acuity improves reimbursement as well as quality metrics. J Vasc Surg 2021; 74:2055-2062. [PMID: 34186163 DOI: 10.1016/j.jvs.2021.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/06/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Accurate documentation of patient care and acuity is essential to determine appropriate reimbursement as well as accuracy of key publicly reported quality metrics. We sought to investigate the impact of standardized note templates by inpatient advanced practice providers (APPs) on evaluation and management (E/M) charge capture, including outside of the global surgical package (GSP), and quality metrics including case mix index (CMI) and mortality index (MI). We hypothesized this clinical documentation initiative as well as improved coding of E/M services would result in increased reimbursement and quality metrics. METHODS A documentation and coding initiative on the heart and vascular service line was initiated in 2016 with focus on improving inpatient E/M capture by APPs outside the GSP. Comprehensive training sessions and standardized documentation templates were created and implemented in the electronic medical record. Subsequent hospital care E/M (current procedural terminology codes 99231, 99232, 99233) from the years 2015 to 2017 were audited and analyzed for charge capture rates, collections, work relative value units (wRVUs), and billing complexity. Data were compared over time by standardizing CMS values and reimbursement rates. In addition, overall CMI and MI were calculated each year. RESULTS One year following the documentation initiative, E/M charges on the vascular surgery service line increased by 78.5% with a corresponding increase in APP charges from 0.4% of billable E/M services to 70.4% when compared with pre-initiative data. The charge capture of E/M services among all inpatients rose from 21.4% to 37.9%. Additionally, reimbursement from CMS increased by 65% as total work relative value units generated from E/M services rose by 78.4% (797 to 1422). The MI decreased over the study period by 25.4%. Additionally, there was a corresponding 5.6% increase in the cohort CMI. Distribution of E/M encounter charges did not vary significantly. Meanwhile, the prevalence of 14 clinical comorbidities in our cohort as well as length of stay (P = .88) remained non-statistically different throughout the study period. CONCLUSIONS Accurate clinical documentation of E/M care and ultimately inpatient acuity is critical in determining quality metrics that serve as important measures of overall hospital quality for CMS value-based payments and rankings. A system-based documentation initiative and expanded role of inpatient APPs on vascular surgery teams significantly improved charge capture and reimbursement outside the GSP as well as CMI and MI in a consistently complex patient population.
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Estrella JB, Carmichael H, Myers QWO, Lee S, Velopulos CG. Making it Complicated: Does Disparity in Access to Care Lead to More Perforated Appendicitis? J Surg Res 2021; 266:405-412. [PMID: 34091088 DOI: 10.1016/j.jss.2021.04.031] [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] [Received: 02/26/2021] [Accepted: 04/16/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Delays in obtaining care may lead to perforated appendicitis, increasing risk of morbidity and mortality. We previously explored the role of social determinants in patients undergoing cholecystectomy, finding that emergent presentation is associated with neighborhood Social Vulnerability Index (SVI). We hypothesize that social vulnerability is associated with increased incidence of perforated appendicitis. METHODS We retrospectively identified patients presenting to our urban, academic hospital with acute appendicitis during a 9-month timeframe (11/2019 - 7/2020). Patients were classified as perforated or non-perforated. Patient SVI was determined using geocoding at the census tract level. Because rates of perforation were higher in older patients, we performed a subset analysis of patients ≥ 40 years. RESULTS 190 patients were included. Patients with perforated appendicitis (n = 48, 25%) were older and were more likely to present to a clinic versus the emergency department (P = 0.009). Perforated patients had longer delay before seeking care (56% versus 6% with > 72 hours of symptoms, P < 0.001). However, there were no differences between groups in terms of sex, race/ethnicity, insurance type, language barrier, having a primary care physician, or any of the SVI subscales. Of patients ≥ 40 years, a higher proportion were perforated (28/80, 35%) despite similar rates of delayed care. In this cohort, higher overall SVI as well as the socioeconomic status and household composition/disability subscales were associated with perforation. CONCLUSIONS Contrary to our hypothesis, while perforation was associated with delayed care in this population, we did not find overall that social vulnerability or individual social determinants accounted for this delay.
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Affiliation(s)
| | - Heather Carmichael
- School of Medicine, University of Colorado, Colorado, USA; Department of Surgery, University of Colorado, Colorado, USA
| | | | - Sterling Lee
- School of Medicine, University of Colorado, Colorado, USA
| | - Catherine G Velopulos
- School of Medicine, University of Colorado, Colorado, USA; Department of Surgery, University of Colorado, Colorado, USA.
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Association of Medicaid Expansion with In-Hospital Outcomes After Abdominal Aortic Aneurysm Repair. J Surg Res 2021; 266:201-212. [PMID: 34022654 DOI: 10.1016/j.jss.2021.02.018] [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] [Received: 08/13/2020] [Revised: 02/08/2021] [Accepted: 02/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Multiple studies have shown improved outcomes and higher utilization of care with the increase of insurance coverage. This study aims to assess whether Medicaid expansion (ME) has changed the utilization and outcomes of abdominal aortic aneurysm (AAA) repair in the United States. DESIGN Retrospective observational study. MATERIALS Data of patients undergoing AAA repair in the Vascular Quality Initiative (2010-2017). METHODS Interrupted time-series (ITS) analysis was utilized to evaluate changes in annual trends of postoperative outcomes after elective AAA repair before and after 2014. We also assessed if these trend changes were significant by comparing the changes in states which adopted ME in 2014 versus nonexpansion states (NME), and conducting a difference-in-difference analysis. Primary outcomes included in-hospital mortality and adverse events (bowel and leg ischemia, cardiac, renal, respiratory, stroke and return to the OR). RESULTS A total of 19,143 procedures were included (Endovascular: 85.8% and open: 14.2%), of which 40.9% were performed in ME States. Compared to preexpansion trends (P1), there was a 2% annual increase in elective AAA repair in ME states (P1: -1.8% versus P2: +0.2%, P< 0.01) with no significant change in NME (P1: +0.3% versus P2: +0.2%, P = 0.97). Among elective cases, annual trends in the use of EVAR increased by 2% in ME states (95% confidence interval (CI) = -0.1, 4.1, P = 0.06), compared to a 3% decrease in NME States [95%CI = -5.8, -0.6, P = 0.01) (PMEversusNME < 0.01]. There was no association between ME and in-hospital mortality. Nonetheless, it was associated with a decrease in the annual trends of in-hospital complications (ME: -1.4% (-2.1,-0.8) versus NME: +0.2% (-0.2, +0.8), P < 0.01). CONCLUSIONS While no association between ME and increased survival was noted in states which adopted ME, there was a significant increase of elective AAA cases and EVAR utilization and a decrease in in-hospital complications in ME States.
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Maduekwe UN, Haynes AB. Toward Quantification of Geographic Disparity in Access to Surgical Care-Betwixt and Between. JAMA Surg 2021; 156:246. [PMID: 33326006 DOI: 10.1001/jamasurg.2020.5669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ugwuji N Maduekwe
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill
| | - Alex B Haynes
- Division of Surgical Oncology, Department of Surgery and Perioperative Care, Dell Medical School University of Texas, Austin
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Predicting NICU admissions in near-term and term infants with low illness acuity. J Perinatol 2021; 41:478-485. [PMID: 32678315 PMCID: PMC7855290 DOI: 10.1038/s41372-020-0723-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/29/2020] [Accepted: 07/07/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Describe NICU admission rate variation among hospitals in infants with birthweight ≥2500 g and low illness acuity, and describe factors that predict NICU admission. STUDY DESIGN Retrospective study from the Vizient Clinical Data Base/Resource Manager®. Support vector machine methodology was used to develop statistical models using (1) patient characteristics (2) only the indicator for the inborn hospital and (3) patient characteristics plus indicator for the inborn hospital. RESULTS NICU admission rates of 427,449 infants from 154 hospitals ranged from 0 to 28.6%. C-statistics for the patient characteristics model: 0.64 (Confidence Interval (CI) 0.62-0.65), hospital only model: 0.81 (CI, 0.81-0.82), and patient characteristic plus hospital variable model: 0.84 (CI, 0.83-0.84). CONCLUSION/RELEVANCE There is wide variation in NICU admission rates in infants with low acuity diagnoses. In all cohorts, birth hospital better predicted NICU admission than patient characteristics alone.
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Anastasio AT, Niu S, Kim EJ, Rhee JM. Evaluating Single-Surgeon Bias Toward Recommending Corrective Procedures for Cervical Spondylotic Myelopathy Based on Demographic Factors and Comorbidities in a 484-Patient Cohort. Global Spine J 2021; 11:167-171. [PMID: 32875846 PMCID: PMC7882819 DOI: 10.1177/2192568219896296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVES An increasing focus has been placed on removing implicit (unconscious) bias from the surgical selection process. In spine surgery, there is the potential for implicit bias to affect the decision to either operate on a patient or not, given lack of definitive surgical indications for many elective procedures. The objective of this study was to analyze the surgical decision making of a single spine surgeon in an effort to understand surgical decision-making trends based on certain demographic factors. METHODS This was a retrospective study of 484 patients who had undergone a corrective procedure for cervical myelopathy by an orthopedic spine surgeon at our institution. The preoperative modified Japanese Orthopaedic Association score served as the metric of severity of disease for cervical myelopathy. The factors that have been associated with implicit bias that were evaluated were smoking status, narcotic use status, gender, body mass index, and age. RESULTS Multivariate linear regression analysis showed that even after controlling for comorbidities and confounders, the only variable which predicted likelihood to operate on a patient of a milder symptomology was age (odds ratio [OR] = -0.138; (confidence interval [CI] = -0.034 to -0.006). The other factors (smoking status, narcotic use status, gender, and body mass index) were not associated with surgical decision making. CONCLUSIONS Our study demonstrates absence of association between commonly studied areas of implicit bias and the decision to operate on a patient with milder symptomology at initial presentation of cervical spondylotic myelopathy.
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Affiliation(s)
| | - Shuo Niu
- Emory University Hospital, Atlanta, GA, USA
| | | | - John M. Rhee
- Emory University Hospital, Atlanta, GA, USA,John M. Rhee, Department of Orthopaedic Surgery, Emory University, Emory Spine Center, 59 Executive Park South, Atlanta, GA 30329, USA.
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Lin S, Brasel KJ, Chakraborty O, Glied SA. Association Between Medicaid Expansion and the Use of Outpatient General Surgical Care Among US Adults in Multiple States. JAMA Surg 2021; 155:1058-1066. [PMID: 32822464 DOI: 10.1001/jamasurg.2020.2959] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Importance The Affordable Care Act expanded access to Medicaid coverage in 2014 for individuals living in participating states. Whether expanded coverage was associated with increases in the use of outpatient surgical care, particularly among underserved populations, remains unknown. Objective To evaluate the association between state participation in the Affordable Care Act Medicaid expansion reform and the use of outpatient surgical care. Design, Setting, and Participants This case-control study used a quasi-experimental difference-in-differences design to compare the use of outpatient surgical care at the facility and state levels by patient demographic characteristics and payer categories (Medicaid, private insurance, and no insurance). Data from 2013 (before Medicaid expansion reform) and 2015 (after Medicaid expansion reform) were obtained from the State Ambulatory Surgery and Services Database of the Healthcare Cost and Utilization Project. The absolute and mean numbers of procedures performed at outpatient surgical centers in 2 states (Michigan and New York) that participated in Medicaid expansion (expansion states) were compared with those performed at outpatient surgical centers in 2 states (Florida and North Carolina) that did not participate in Medicaid expansion (nonexpansion states). The population-based sample included 207 176 patients aged 18 to 64 years who received 4 common outpatient procedures (laparoscopic cholecystectomy, breast lumpectomy, open inguinal hernia repair, and laparoscopic inguinal hernia repair). Data were analyzed from May 19 to August 25, 2019. Interventions State variation in the adoption of Medicaid expansion before and after expansion reform was implemented through the Affordable Care Act. Main Outcomes and Measures Changes in the mean number of procedures performed at the facility level before and after Medicaid expansion reform in states with and without expanded Medicaid coverage. Results A total of 207 176 patients (106 395 women [51.35%] and 100 781 men [48.65%]; mean [SD] age, 45.7 [12.4] years) were included in the sample. Overall, 116 752 procedures were performed in Medicaid expansion states and 90 424 procedures in nonexpansion states. A 9.8% increase (95% CI, 0.4%-20.0%; P = .04) in cholecystectomies, a 26.1% increase (95% CI, 9.8%-44.7%; P = .001) in lumpectomies, and a 16.3% increase (95% CI, 2.9%-31.5%; P = .02) in laparoscopic inguinal hernia repairs were observed at the facility level in expansion states compared with nonexpansion states. Among patients with Medicaid coverage, the mean number of procedures performed in all 4 procedure categories increased between 60.5% (95% CI, 24.7%-106.6%; P < .001) and 79.2% (95% CI, 53.5%-109.2%; P < .001) at the facility level. The increases in the number of Medicaid patients who received treatment exceeded the reductions in the number of uninsured patients who received treatment with laparoscopic cholecystectomy, open inguinal hernia repair, and laparoscopic inguinal hernia repairs in expansion states compared with nonexpansion states. Black patients received more laparoscopic cholecystectomies, lumpectomies, and open inguinal hernia repairs in expansion states than in nonexpansion states. Conclusions and Relevance Study results suggest that Medicaid expansion was associated with increases in the use of outpatient surgical care in states that participated in Medicaid expansion. Most of this increase represented patients who were newly treated rather than patients who converted from no insurance to Medicaid coverage.
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Affiliation(s)
- Saunders Lin
- Department of Surgery, Oregon Health and Science University, Portland.,Wagner School of Public Policy, New York University, New York
| | - Karen J Brasel
- Department of Surgery, Oregon Health and Science University, Portland
| | | | - Sherry A Glied
- Wagner School of Public Policy, New York University, New York
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Yan LD, Ali MK, Strombotne KL. Impact of Expanded Medicaid Eligibility on the Diabetes Continuum of Care Among Low-Income Adults: A Difference-in-Differences Analysis. Am J Prev Med 2021; 60:189-197. [PMID: 33191065 PMCID: PMC10420391 DOI: 10.1016/j.amepre.2020.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/31/2020] [Accepted: 08/06/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The impact of Medicaid expansion on linkage to care, self-maintenance, and treatment among low-income adults with diabetes was examined. METHODS A difference-in-differences design was used on data from the Behavioral Risk Factor Surveillance System, 2008-2018. Analysis was restricted to states with diabetes outcomes and nonpregnant adults aged 18-64 years who were Medicaid eligible on the basis of income. Separate analyses were performed for early postexpansion (1, 2, 3) and late postexpansion years (4, 5). Analyses were performed from September 2019 to March 2020. RESULTS In comparing expansion with control states, low-income residents with diabetes had similar ages (48.9 vs 49.1 years) and similar proportions who were female (54.4% vs 55.0%) but were less likely to be Black, non-Hispanic (20.8% vs 29.2%, standardized difference= -16.3%). In expansion states, health insurance increased by 7.2 percentage points (95% CI=3.9, 10.4), and the ability to afford a physician increased by 5.5 percentage points (95% CI=1.9, 9.1) in the early years, but no difference was found in late years. Medicaid expansion led to a 5.3-percentage point increase in provider foot examinations in the early period (95% CI=0.14, 10.4) and a 7.2-percentage point increase in self-foot examinations in the late period (95% CI=1.1, 13.3). No statistically significant changes were detected in self-reported linkage to care, self-maintenance, or treatment. CONCLUSIONS Although health insurance, ability to afford a physician visit, and foot examinations increased for Medicaid-eligible people with diabetes, there was no statistically significant difference found for other care continuum measures.
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Affiliation(s)
- Lily D Yan
- Department of Internal Medicine, Boston Medical Center, Boston, Massachusetts; Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts.
| | - Mohammed K Ali
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia; Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kiersten L Strombotne
- Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
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