Association of Race, Health Insurance Status, and Household Income With Location and Outcomes of Ambulatory Surgery Among Adult Patients in 2 US States

Ambulatory surgery center versus outpatient hospitals: a comparison of reimbursements for patients undergoing anterior cervical discectomy and fusion

BACKGROUND CONTEXT

While some studies have demonstrated that ambulatory surgery centers (ASCs) are associated with reduced costs of orthopedic procedures, there is no consensus in the current literature as to the impact of ASCs versus hospital-based outpatient departments (HOPDs) on anterior cervical discectomies and fusions (ACDFs).

PURPOSE

This study sought to (1) compare immediate procedure reimbursements, patient out-of-pocket expenditures, and surgeon reimbursements for ACDFs performed at ASCs versus HOPDs and (2) identify factors predicting facility utilization.

STUDY DESIGN

Retrospective cross-sectional study.

PATIENT SAMPLE

We identified ACDF procedures performed at an ASC or HOPD in commercially-insured patients aged 18 to 64.

OUTCOME MEASURES

Payment variables were calculated from claims within 3 days preoperatively and postoperatively.

METHODS

Multivariable regression models assessed (1) associations between the surgery setting and payment variables and (2) factors associated with the surgery setting.

RESULTS

We included 18,191 ACDFs (14.8% ASC, 85.2% HOPD). In multivariable analyses, ACDFs performed in an ASC (versus HOPD) were associated with 9.8% higher immediate procedure reimbursements (95% CI:7.5%-12.2%), 17.2% higher patient out-of-pocket expenditures (95% CI:11.8-22.8), and 11.7% higher surgeon reimbursements (95% CI:9.18-14.2; all p<.01) (all p<.001). Surgery setting utilization varied by region, insurance-related factors, comorbidities, and procedural complexity.

CONCLUSIONS

We found that ASCs had significantly higher reimbursements compared to HOPDs. Regional variations in ASC utilization imply there are opportunities for standardization of care.

LEVEL OF EVIDENCE: 3

Outpatient surgical institutions in the rural United States: Trends from 2010 to 2020

BACKGROUND

The volume and proportion of surgeries occurring in outpatient settings has increased. However, the growth and distribution of outpatient surgical institutions, namely ambulatory surgery centers (ASCs) and hospital-based outpatient surgical departments (HOPDs), remains understudied in rural areas.

METHODS

We used descriptive statistics and a multivariate logistic regression to assess the growth and distribution of ASCs and HOPDs in rural areas from 2010 to 2020, leveraging the Area Health Resources Files and American Community Survey.

RESULTS

From 2010 to 2020, the number of ASCs in rural counties decreased by 4.9 ​% (410 vs. 390), and rural HOPDs decreased by 14.3 ​% (1400 vs. 1200). Completely rural counties were over five times likelier to lack both ASCs and HOPDs (AOR ​= ​5.32; 95 ​% CI ​= ​[4.82-5.89]); p ​< ​0.001).

CONCLUSIONS

Outpatient surgical institution access in rural America declined. Policymakers should protect rural HOPDs, promote the creation of ASCs in rural communities, and incentivize surgeons to enter rural practice.

A comparison study of 90-day readmission and emergency department visitation after outpatient versus inpatient pediatric pollicization surgery

Introduction

Transition to outpatient surgery has grown with an emphasis on delivery of safe, high-quality medical care. The purpose of this study is to compare 90-day emergency department (ED) visits, readmissions, and complications between patients undergoing outpatient versus inpatient pollicization surgery.

Methods

A single institution database was queried for primary thumb pollicization from 2010 to 2022 in patients under 18 years of age. Standard demographic data, comorbidities, surgical information, and discharge disposition were collected. Primary outcome measures were complications including ED visits, unplanned reoperations and hospital readmissions within 90-days of index procedure.

Results

Twenty-seven patients underwent pollicization surgery. Twenty patients were outpatient surgery while 7 had postoperative hospital admission, defined as an overnight hospital stay. The outpatient cohort had no major postoperative complications including no ED visits, reoperations or readmissions within 90 days of index procedure. One outpatient experienced swelling around bilateral thumb pin sites without infection or vascular compromise. One inpatient represented to the ED within 90 days of surgery for bilateral hand cellulitis.All patients with ASA I classification were performed outpatient. Three of 7 inpatients (43 %) had congenital heart disease versus 5 of the 20 (25 %) outpatients. There was a trend that inpatients were younger than the outpatient cohort (19 vs. 33 months). The average length of procedure in the inpatient cohort was significantly longer than the outpatient cohort (237 vs. 173 min). Pollicizations performed between 2017 and 2022 were more likely to be outpatient than those performed between 2010 and 2016.

Conclusion

On properly selected patients, outpatient pollicization appears to be a safe option. Patients with longer operative times were more likely to require postoperative hospital admission. Over the study years evaluated at our institution, pollicization procedures were more likely to be performed outpatient, reflecting an evolution of our practice.

Level of evidence

Level III, retrospective cohort study.

2020 CMS prior authorization for hospital outpatient departments: Associated surgical volume impact

BACKGROUND

Prior authorization is common for privately administered Medicare Advantage plans but is rarely used for surgical care when considering publicly administered plans. A 2020 Centers for Medicare and Medicaid services (CMS) policy, CMS-1717-FC, requires prior authorization for Medicare Fee-for-Service beneficiaries undergoing select procedures (blepharoplasty, abdominoplasty, botulinum toxin injection, rhinoplasty, and vein ablation) in hospital outpatient departments. The impact of this policy on surgical volume at hospital outpatient departments and shifts in care to ambulatory surgery centers is unknown.

METHODS

This study used a segmented interrupted time series and pre-post logistic regression model. This study was a retrospective cohort study using data from the Healthcare Cost and Utilization Project state ambulatory surgery database and state inpatient database.

RESULTS

From 2016 through 2021, a total of 272,879 patients underwent the affected procedures. Pre-CMS-1717-FC, a trend of decreasing hospital outpatient department utilization was found for Medicare Fee-for-Service beneficiaries (-10.82, 95% confidence interval: -18.32 to -3.33, P = .01). In the post-implementation period, no change in the rate of decreasing hospital outpatient department utilization was found for Medicare Fee-for-Service beneficiaries (-3.45, 95% confidence interval: -36.15 to 29.25, P = .83). In the pre-policy period, Medicare Fee-for-Service beneficiaries were 46% less likely to use freestanding ambulatory surgery centers but 27% less likely to use hospital-owned ambulatory surgery centers.

CONCLUSION

CMS-1717-FC was not associated with significant changes in hospital outpatient department volume beyond baseline trends. Policy aiming to right-size prior authorization for these procedures and considering site-of-service will balance the need to ensure medical necessity while constraining costs.

Postoperative racial disparities following spine surgery are less pronounced in the outpatient setting

BACKGROUND CONTEXT

Racial disparities in spine surgery have been thoroughly documented in the inpatient (IP) setting. However, despite an increasing proportion of procedures being performed as same-day surgeries, whether similar differences have developed in the outpatient (OP) setting remains to be elucidated.

PURPOSE

This study aimed to investigate racial differences in postoperative outcomes between Black and White patients following OP and IP lumbar and cervical spine surgery.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021.

OUTCOME MEASURES

Thirty-day rates of serious and minor adverse events, readmission, reoperation, nonhome discharge, and mortality.

METHODS

A retrospective review of patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021 was conducted using the National Surgical Quality Improvement Program (NSQIP) database. Disparities between Black and White patients in (1) adverse event rates, (2) readmission rates, (3) reoperation rates, (4) nonhome discharge rates, (5) mortality rates, (6) operative times, and (7) hospital LOS between Black and White patients were measured and compared between IP and OP surgical settings. Multivariable logistic regression analyses were used to adjust for potential effects of baseline demographic and clinical differences.

RESULTS

Of 81,696 total surgeries, 49,351 (60.4%) were performed as IP and 32,345 (39.6%) were performed as OP procedures. White patients accounted for a greater proportion of IP (88.2% vs 11.8%) and OP (92.7% vs 7.3%) procedures than Black patients. Following IP surgery, Black patients experienced greater odds of serious (OR 1.214, 95% CI 1.077-1.370, p=.002) and minor adverse events (OR 1.377, 95% CI 1.113-1.705, p=.003), readmission (OR 1.284, 95% CI 1.130-1.459, p<.001), reoperation (OR 1.194, 95% CI 1.013-1.407, p=.035), and nonhome discharge (OR 2.304, 95% CI 2.101-2.528, p<.001) after baseline adjustment. Disparities were less prominent in the OP setting, as Black patients exhibited greater odds of readmission (OR 1.341, 95% CI 1.036-1.735, p=.026) but were no more likely than White patients to experience adverse events, reoperation, individual complications, nonhome discharge, or death (p>.050 for all).

CONCLUSIONS

Racial inequality in postoperative complications following spine surgery is evident, however disparities in complication rates are relatively less following OP compared to IP procedures. Further work may be beneficial in elucidating the causes of these differences to better understand and mitigate overall racial disparities within the inpatient setting. These decreased differences may also provide promising indication that progress towards reducing inequality is possible as spine care transitions to the OP setting.

Potential US Health Care Savings Based on Clinician Views of Feasible Site-of-Care Shifts

Importance

Shifting care to alternative sites when clinically appropriate may be associated with reduced US health care spending, improved access, and, in some cases, improved care outcomes.

Objective

To fill 2 main gaps in the current literature on site-of-care shifts: (1) understanding the clinician perspective on appropriateness of alternative care sites, given the central role they play in referrals and patient trust and (2) considering all potential sites where care could shift and calculating net savings potential.

Design, Setting, and Participants

In this survey study, physicians (MDs and DOs), nurse practitioners, physician assistants, nurse anesthetists, radiology and imaging technicians, and psychologists were surveyed from September 17 to November 22, 2021, about potential shifts of care from the hospital setting to alternative sites. Participants were selected by the survey firm Intellisurvey to provide broad representation across all specialties of interest. A minimum of 34 clinicians responded to each question. Data were analyzed from April 2022 through October 2023.

Exposure

More than 5000 individual diagnostic and procedural codes were reviewed and sorted into 312 distinct care activities by an expert panel of physicians. Survey respondents were then provided with the 2019 claims-based distribution across sites of care for each care activity and were asked, "based on your clinical judgment, what portion of [care activity] could safely occur in each of the following sites of care, without compromising clinical outcomes?"

Main Outcomes and Measures

Based on clinician-reported distributions, the total potential shift of volume from hospital-based settings to alternative sites and the associated net savings were estimated.

Results

Survey respondents included 1069 practicing clinicians (386 female [36.1%]; mean [SD] years since residency of physicians, 21.0 [9.7] years; mean [SD] age of nonphysicians, 45.3 [9.4] years) across specialties, all of whom practiced more than 20 clinical hours per week. There were 794 physicians (74.3%), and the remaining 275 respondents were midlevel professionals, such as physician assistants. Among 312 care activities surveyed, respondents indicated that 10.3 percentage points (95% CI, 10.0-10.5 percentage points) of commercial and 10.9 percentage points (95% CI, 10.7-11.1 percentage points) of Medicare volume currently taking place in hospital-based settings could shift to alternative sites with today's technology without compromising clinical outcomes. Across the entire US health care system, these shifts could be associated with a reduction in overall health care consumption spending ($3 562 339 000 000 000) by approximately $113.8 billion ($113 767 446 087 174 [3.2%]) to $147.7 billion ($147 661 672 284 263 [4.1%]) annually.

Conclusions and relevance

In this study, a substantial net savings opportunity was estimated. However, realizing this potential will require ongoing alignment among organizations, clinicians, and policymakers to overcome barriers to these shifts.

Race and socioeconomic disparities persist in treatment and outcomes of patients with cervical spinal cord injuries: An analysis of the national inpatient sample from 2016 - 2020

Objective

Previous literature has described race and socioeconomic disparities in both treatment and outcomes following cervical spinal cord injuries (SCI). The goal of this study is to investigate the current state of parity in management and outcomes following SCI.

Methods

We surveyed the National Inpatient Sample database (NIS) for patients admitted with primary diagnosis of cervical SCI. 49,320 patients were identified. Univariate and multivariate analyses were performed to evaluate racial and socioeconomic differences in SCI care and outcomes.

Results

Compared to white patients, minority race was associated with a longer time from presentation to operative intervention (p < 0.001) and longer length of stay following admission for cervical SCI (16 vs 13 days, p < 0.001). Minority patients were more likely to have an unfavorable discharge (skilled nursing facility, against medical advice, death) status than white patients (p < 0.001). Patients in the bottom quartile of median household income were associated with more unfavorable discharges than the top two quartiles (p < 0.001). Patients with the lowest median household income quartile also had higher total costs than those in the top quartiles ($221,654 vs 191,723, p < 0.001). Black, Hispanic, and Asian/Pacific Islander incurred higher treatment costs than White patients.

Conclusion

Minority and lower socioeconomic status are independently associated with unfavorable discharge and LOS in cervical SCI. Furthermore, racial and economically disadvantaged groups have longer wait times from admission to surgical intervention. These disparities persist despite being highlighted by previous publications and increased societal awareness of healthcare inequities, necessitating further work to reach parity.

Incomes to Outcomes: A Global Assessment of Disparities in Cleft and Craniofacial Treatment

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.

Socioeconomic status is associated with pediatric adenotonsillectomy outcomes: A single institution study

OBJECTIVE

Our institution serves a diverse patient population across a large metropolitan city. Literature has shown pediatric otolaryngology patients with lower socioeconomic status (SES) have higher rates of sleep-disordered breathing, delays in treatment time, and greater risks of complications post-tonsillectomy. This study aims to examine the effects of SES on adenotonsillectomy outcomes performed at our institution.

STUDY DESIGN

A retrospective chart review including 1560 pediatric patients (ages 0-18) who underwent adenotonsillectomy between January 2015 and December 2020.

SETTING

Large metropolitan hospital, level 1 trauma center.

METHODS

Outcome variables included postoperative hospital admission, phone calls, 30-day follow-up, and persistent obstructive sleep apnea (OSA). Descriptive statistics using Wilcoxon Signed Rank Tests and univariate and multivariate logistic regression modeling were used to determine statistically significant covariates at α = 0.05.

RESULTS

The cohort included Non-Hispanic White (n = 488, 31 %), Non-Hispanic Black (n = 801, 51 %), Hispanic (n = 210, 13 %), and other (n = 61, 4 %) groups. Using multivariate regression, privately insured patients were less likely to have moderate-to-severe OSA before surgery (0.65 95 % CI 0.45, 0.93 p = 0.017) and be admitted postoperatively (0.73, 0.55-0.96, p < 0.01), while more likely to have postoperative follow-up phone calls (1.57, 1.19-2.09, p < 0.01) and visits (1.53, 1.22-1.92, p < 0.01). Increased income was associated with decreased rehospitalizations within three months of surgery (0.98, 0.97-1.00, p < 0.01).

CONCLUSION

This study suggests SES significantly affects adenotonsillectomy outcomes. Further studies are warranted to provide better care for all pediatric patients.

Emergency Department Visit Rates After Ambulatory Surgery

This cohort study compares the rates of emergency department visits after cholecystectomy, transurethral resection of the prostate, and knee arthroplasty at freestanding ambulatory surgery centers vs hospital-owned surgery centers.

Outpatient Total Ankle Arthroplasty (TAA) as a Rising Alternative to Inpatient TAA: A Database Analysis

BACKGROUND

There is growing evidence that total ankle arthroplasty (TAA) can safely be performed as an outpatient procedure, with the benefit of decreased health care expenses and improved patient satisfaction. The purpose of our study was to compare readmissions, arthroplasty failures, infections, and annual trends between outpatient and inpatient TAA using a large publicly available for-fee database.

METHODS

The PearlDiver Database was queried to identify outpatient and inpatient TAA-associated claims for several payer types from January 2010 to October 2021. Preoperative patient characteristics and annual trends were compared for inpatient and outpatient TAA. International Classification of Diseases, Ninth and Tenth Revision, diagnosis codes were used to identify infections and arthroplasty failures. Complications rates were compared after matching patients by age, gender, and the following comorbidities: diabetes, smoking, congestive heart failure (CHF), hypertension (HTN), obesity, and chronic kidney disease (CKD).

RESULTS

A total of 12 274 patients were included in the final exact-matched analysis for complications, with 6137 patients in each group. Outpatients had a significantly lower rate of readmission within 90 days (2.6% vs 4.0%, P < .001), arthroplasty failure (4.1% vs 6.9%, P < .001), and infection (2.4% vs 3.1%, P = .015). Among database enrollees, outpatient TAA has risen in proportion to inpatient TAA from 2019 to 2021.

CONCLUSION

Outpatient TAA had lower rates of risk-adjusted readmission, arthroplasty failure, and infection compared to inpatient TAA.

LEVEL OF EVIDENCE

Level III, retrospective comparative database study.

Medicare Eligibility and Racial and Ethnic Disparities in Operative Fixation for Distal Radius Fracture

Importance

Medicare provides near-universal health insurance to US residents aged 65 years or older. How eligibility for Medicare coverage affects racial and ethnic disparities in operative management after orthopedic trauma is poorly understood.

Objective

To assess the association of Medicare eligibility with racial and ethnic disparities in open reduction and internal fixation (ORIF) after distal radius fracture (DRF).

Design, Setting, and Participants

This retrospective cohort study with a regression discontinuity design obtained data from the Healthcare Cost and Utilization Project all-payer statewide databases for Florida, Maryland, and New York. These databases contain encounter-level data and unique patient identifiers for longitudinal follow-up across emergency departments, outpatient surgical centers, and hospitals. The cohort included patients aged 57 to 72 years who sustained DRFs between January 1, 2016, and November 30, 2019. Data analysis was performed between March 1 and October 15, 2023.

Exposure

Eligibility for Medicare coverage at age 65 years.

Main Outcomes and Measures

Type of management for DRF (closed treatment, external fixation, percutaneous pinning, and ORIF). Time to surgery was ascertained in patients undergoing ORIF. Multivariable logistic regression and regression discontinuity design were used to compare racial and ethnic disparities in patients who underwent ORIF before or after age 65 years.

Results

A total of 26 874 patients with DRF were included (mean [SD] age, 64.6 [4.6] years; 22 359 were females [83.2%]). Of these patients, 2805 were Hispanic or Latino (10.4%; hereafter, Hispanic), 1492 were non-Hispanic Black (5.6%; hereafter, Black), and 20 548 were non-Hispanic White (76.5%; hereafter, White) and 2029 (7.6%) were individuals of other races and ethnicities (including Asian or Pacific Islander, Native American, and other races). Overall, 32.6% of patients received ORIF but significantly lower use was observed in Black (20.2% vs 35.4%; P < .001) and Hispanic (25.8% vs 35.4%; P < .001) patients compared with White individuals. After adjusting for potential confounders, multivariable logistic regression analysis confirmed the disparity in ORIF use in Black (odds ratio [OR], 0.60; 95% CI, 0.50-0.72) and Hispanic patients (OR, 0.82; 95% CI, 0.72-0.94) compared with White patients. No significant difference in ORIF use was found among racial and ethnic groups at age 65 years. The expected disparity in ORIF use between White and Black patients at age 65 years without Medicare coverage was 12.6 percentage points; however, the actual disparity was 22.0 percentage points, 9.4 percentage points (95% CI, 0.3-18.4 percentage points) greater than expected, a 75% increase (P = .04). In the absence of Medicare coverage, the expected disparity in ORIF use between White and Hispanic patients was 8.3 percentage points, and this result persisted without significant change in the presence of Medicare coverage.

Conclusions and Relevance

Results of this study showed that surgical management for DRF was popular in adults aged 57 to 72 years, but there was lower ORIF use in racial or ethnic minority patients. Medicare eligibility at age 65 years did not attenuate race and ethnicity-based disparities in surgical management of DRFs.

Improving Racial and Ethnic Disparities in Outpatient Anterior Cervical Discectomy and Fusion Driven by Increasing Utilization of Ambulatory Surgical Centers in New York State

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study was to assess trends in disparities in utilization of hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) for outpatient ACDF (OP-ACDF) between White, Black, Hispanic, and Asian/Pacific Islander patients from 2015 to 2018 in New York State.

SUMMARY OF BACKGROUND DATA

Racial and ethnic disparities within the field of spine surgery have been thoroughly documented. To date, it remains unknown how these disparities have evolved in the outpatient setting alongside the rapid emergence of ASCs and whether restrictive patterns of access to these outpatient centers exist by race and ethnicity.

MATERIALS AND METHODS

We conducted a retrospective review from 2015 to 2018 using the Healthcare Cost and Utilization Project (HCUP) New York State Ambulatory Database. Differences in utilization rates for OP-ACDF were assessed and trended over time by race and ethnicity for both HOPDs and freestanding ASCs. Poisson regression was used to evaluate the association between utilization rates for OP-ACDF and race/ethnicity.

RESULTS

Between 2015 and 2018, Black, Hispanic, and Asian patients were less likely to undergo OP-ACDF compared with White patients in New York State. However, the magnitude of these disparities lessened over time, as Black, Hispanic, and Asian patients had greater relative increases in utilization of HOPDs and ASCs for ACDF when compared with White patients ( Ptrend <0.001). The magnitude of the increase in freestanding ASC utilization was such that minority patients had higher ACDF utilization rates in freestanding ASCs by 2018 ( P <0.001).

CONCLUSIONS

We found evidence of improving racial disparities in the relative utilization of outpatient ACDF in New York State. The increase in access to outpatient ACDF appeared to be driven by an increasing number of patients undergoing ACDF in freestanding ASCs in large metropolitan areas. These improving disparities are encouraging and contrast previously documented inequalities in inpatient spine surgery.

LEVEL OF EVIDENCE

III.

Freestanding Ambulatory Surgery Centers and Patients Undergoing Outpatient Knee Arthroplasty

Importance

In 2018, Medicare removed total knee arthroplasty from the list of inpatient-only procedures, resulting in a new pool of patients eligible for outpatient total knee arthroplasty. How this change was associated with the characteristics of patients undergoing outpatient knee arthroplasty at hospital-owned surgery centers (HOSCs) vs freestanding ambulatory surgery centers (FASCs) is unknown.

Objectives

To describe the characteristics of patients undergoing outpatient, elective total and partial knee arthroplasty in 2017 and 2018 and to compare the cohorts receiving treatment at FASCs and HOSCs.

Design, Setting, and Participants

This observational retrospective cohort study included 5657 patients having elective, outpatient partial and total knee arthroplasty in the Florida and Wisconsin State Ambulatory Surgery Databases in 2017 and 2018. Prior admissions were identified in the State Inpatient Database. Statistical analysis was performed from March to June 2022.

Main Outcomes and Measures

Characteristics of patients undergoing surgery at a FASC vs a HOSC in 2017 and 2018 were compared.

Results

A total of 5657 patients (mean [SD] age, 64.2 [9.9] years; 2907 women [51.4%]) were included in the study. Outpatient knee arthroplasties increased from 1910 in 2017 to 3747 in 2018 and were associated with an increase in total knee arthroplasties (474 in 2017 vs 2065 in 2018). The influx of patients undergoing outpatient knee arthroplasty was associated with an amplification of differences between the patients treated at FASCs and the patients treated at HOSCs. Patients with private payer insurance seen at FASCs increased from 63.4% in 2017 (550 of 867) to 72.7% in 2018 (1272 of 1749) (P < .001), while the percentage of patients with private payer insurance seen at HOSCs increased, but to a lesser extent (41.6% [427 of 1027] in 2017 vs 46.4% [625 of 1346] in 2018; P < .001). In 2017, the percentages of White patients seen at FASCs and HOSCs were similar (85.0% [737 of 867] vs 88.2% [906 of 1027], respectively); in 2018, the percentage of White patients seen at FASCs had increased and was significantly different from the percentage of White patients seen at HOSCs (90.6% [1585 of 1749] vs 87.9% [1183 of 1346]; P = .01). Both types of facilities saw an increase from 2017 to 2018 in the percentage of patients from communities of low social vulnerability, but this increase was greater for FASCs (FASCs: 6.7% [58 of 867] in 2017 vs 33.9% [593 of 1749] in 2018; HOSCs: 7.6% [78 of 1027] in 2017 vs 21.2% [285 of 1346] in 2018). Finally, while FASCs and HOSCs had cared for a similar portion of patients with prior admissions in 2017 (7.8% [68 of 867] vs 9.4% [97 of 1027], respectively; P = .25), in 2018, FASCs cared for fewer patients with prior admissions than HOSCs (4.0% [70 of 1749] vs 8.1% [109 of 1346]; P < .001).

Conclusions

This study suggests that the increase in the number of patients undergoing outpatient knee arthroplasty in 2018 corresponded to FASCs treating a greater share of patients who were White, covered by private payer insurance, and healthier. These findings raise a concern that as more operations transition to the outpatient setting, variability in access to FASCs may increase, leaving hospital-owned centers to bear a greater share of the burden of caring for more vulnerable patients with more severe illness.

Value of Ambulatory Modified Radical Mastectomy

BACKGROUND

Modified radical mastectomy (MRM) still is largely performed in inpatient settings. This study sought to determine the value (expenditures and complications) of ambulatory MRM.

METHODS

Health Care Utilization Project (HCUP) state databases from 2016 were queried for patients who underwent MRM. The study examined rates of 30-day readmission for surgical-site infection (SSI) or hematoma, charges by index care setting, and predictors of 30-day readmission.

RESULTS

Overall, 8090 patients underwent MRM: 5113 (63 %) inpatient and 2977 (37 %) ambulatory patients. Compared with the patients who underwent inpatient MRM, those who underwent ambulatory MRM were older (61 vs. 59 years), more often white (66 % vs. 57 %), in the lowest income quartile (28 % vs. 21 %), insured by Medicare (43 % vs. 33 %) and residents in a small metro area (6 % vs. 4 %) (all p < 0.01). Of the 5113 patients treated as inpatients, 126 (2.5 %) were readmitted, whereas 50 (1.7 %) of the ambulatory patients were readmitted (p = 0.02). The adjusted charge for inpatient MRM without readmission was $113,878 (range, $107,355-120,402) compared with $94,463 (range, $86,021-102,907) for ambulatory MRM, and the charge for inpatient MRM requiring readmission was $159,355 (range, $147,142-171,568) compared with $139,940 (range, $125,808-154,073) for ambulatory MRM (all p < 0.01). This difference remained significant after adjustment for hospital length of stay. Adjusted logistic regression showed that the ambulatory setting was protective for readmission (odds ratio, 0.49; 95 % confidence interval, 0.35-0.70; p < 0.01).

CONCLUSIONS

The analyses suggest that ambulatory MRM is both safe and less expensive. The findings advocate that MRM, a last holdout of inpatient care within breast surgical oncology, can be transitioned to the ambulatory setting for appropriate patients.

National Patterns in Utilization of Knee and Hip Arthroscopy: An Analysis of Racial, Ethnic, and Geographic Disparities in the United States

Background

Racial and ethnic disparities in the field of orthopaedic surgery have been reported extensively across many subspecialties. However, these data remain relatively sparse in orthopaedic sports medicine, especially with respect to commonly performed procedures including knee and hip arthroscopy.

Purpose

To assess (1) differences in utilization of knee and hip arthroscopy between White, Black, Hispanic, and Asian or Pacific Islander patients in the United States (US) and (2) how these differences vary by geographical region.

Study Design

Descriptive epidemiology study.

Methods

The study sample was acquired from the 2019 National Ambulatory Surgery Sample database. Racial and ethnic differences in age-standardized utilization rates of hip and knee arthroscopy were calculated using survey weights and population estimates from US census data. Poisson regression was used to model age-standardized utilization rates for hip and knee arthroscopy while controlling for several demographic and clinical variables.

Results

During the study period, rates of knee arthroscopy utilization among White patients were significantly higher than those of Black, Hispanic, and Asian or Pacific Islander patients (ie, per 100,000, White: 180.5, Black: 113.2, Hispanic: 122.2, and Asian: 58.6). Disparities were even more pronounced among patients undergoing hip arthroscopy, with White patients receiving the procedure at almost 4 to 5 times higher rates (ie, per 100,000, White: 12.6, Black: 3.2, Hispanic: 2.3, Asian or Pacific Islander: 1.8). Disparities in knee and hip arthroscopy utilization between White and non-White patients varied significantly by region, with gaps in knee arthroscopy being most pronounced in the Midwest (adjusted rate ratio, 2.0 [95% CI, 1.9-2.1]) and those in hip arthroscopy being greatest in the West (adjusted rate ratio, 5.3 [95% CI, 4.9-5.6]).

Conclusion

Racial and ethnic disparities in the use of knee and hip arthroscopy were found across the US, with decreased rates among Black, Hispanic, and Asian or Pacific Islander patients compared with White patients. Disparities were most pronounced in the Midwest and South and greater for hip than knee arthroscopy, possibly demonstrating emerging inequality in a rapidly growing and evolving procedure across the country.

Surgical Management of Facial Paralysis: Demographic and Socioeconomic Associations

Objective: To determine demographic and socioeconomic variables associated with whether surgery is performed for patients with facial paralysis (FP). Background: Management of FP may include elective surgery dependent on patient goals of care and physician experience. Methods: The 2016 State Inpatient Database and State Ambulatory Surgery Services Database for six states were queried to identify patients with FP. These patients were then stratified based on receiving surgery for FP. Demographic and socioeconomic information was collected. Multivariable logistic regression modeling was used to identify predictors of undergoing FP surgery, as well as the hospital setting in which surgery was performed. Results: Of 20,218 patients with FP, 515 underwent surgery. Black patients were significantly less likely to undergo surgery (p < 0.001), as were patients with Medicaid or self-pay insurance (p < 0.001). Those living in rural areas were also less likely to receive surgery (p = 0.001). Individuals receiving surgery in the inpatient setting were more likely to have private insurance, whereas those in the ambulatory setting were more likely to have Medicare (p < 0.001). Conclusion: Several variables are correlated with whether FP is managed surgically, including insurance status, race, and type of residential area.

Emerging Racial Disparities in Outpatient Utilization of Total Joint Arthroplasty

BACKGROUND

Racial and ethnic disparities within the field of total joint arthroplasty (TJA) have been extensively reported. To date, however, it remains unknown how these disparities have translated to the outpatient TJA (OP-TJA) setting. The purposes of this study were to compare relative OP-TJA utilization rates between White and Black patients from 2011-2019 and assess how these differences in utilization have evolved over time.

METHODS

We conducted a retrospective review from 2011-2019 using the National Surgical Quality Improvement Program (NSQIP). Differences in the relative utilization of OP (same-day discharge) versus inpatient TJA between White and Black patients were assessed and trended over time. Multivariable logistic regressions were run to adjust for baseline patient factors and comorbidities.

RESULTS

During the study period, Black patients were significantly less likely to undergo OP-TJA when compared to White patients (P < .001 for both outpatient total knee arthroplasty and outpatient total hip arthroplasty [OP-THA]). From 2011 to 2019, an emerging disparity was found in outpatient total knee arthroplasty and OP-THA utilization between White and Black patients (eg, White versus Black OP-THA: 0.4% versus 0.6% in 2011 compared with 10.2% versus 5.9% in 2019, P_trend < .001). These results held in all adjusted analyses.

CONCLUSION

In this study we found evidence of emerging and worsening racial disparities in the relative utilization of OP-TJA procedures between White and Black patients. These results highlight the need for early intervention by orthopaedic surgeons and policy makers alike to address these emerging inequalities in access to care before they become entrenched within our systems of orthopaedic care.

Does Age Younger Than 65 Affect Clinical Outcomes in Medicare Patients Undergoing Lumbar Fusion?

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

To determine if age (younger than 65) and Medicare status affect patient outcomes following lumbar fusion.

SUMMARY OF BACKGROUND DATA

Medicare is a common spine surgery insurance provider, but most qualifying patients are older than age 65. There is a paucity of literature investigating clinical outcomes for Medicare patients under the age of 65.

MATERIALS AND METHODS

Patients 40 years and older who underwent lumbar fusion surgery between 2014 and 2019 were queried from electronic medical records. Patients with >2 levels fused, >3 levels decompressed, incomplete patient-reported outcome measures (PROMs), revision procedures, and tumor/infection diagnosis were excluded. Patients were placed into 4 groups based on Medicare status and age: no Medicare under 65 years (NM<65), no Medicare 65 years or older (NM≥65), yes Medicare under 65 (YM<65), and yes Medicare 65 years or older (YM≥65). T tests and χ 2 tests analyzed univariate comparisons depending on continuous or categorical type. Multivariate regression for ∆PROMs controlled for confounders. Alpha was set at 0.05.

RESULTS

Of the 1097 patients, 567 were NM<65 (51.7%), 133 were NM≥65 (12.1%), 42 were YM<65 (3.8%), and 355 were YM≥65 (32.4%). The YM<65 group had significantly worse preoperative Visual Analog Scale back ( P =0.01) and preoperative and postoperative Oswestry Disability Index (ODI), Short-Form 12 Mental Component Score (MCS-12), and Physical Component Score (PCS-12). However, on regression analysis, there were no significant differences in ∆PROMs for YM <65 compared with YM≥65, and NM<65. NM<65 (compared with YM<65) was an independent predictor of decreased improvement in ∆ODI following surgery (β=12.61, P =0.007); however, overall the ODI was still lower in the NM<65 compared with the YM<65.

CONCLUSION

Medicare patients younger than 65 years undergoing lumbar fusion had significantly worse preoperative and postoperative PROMs. The perioperative improvement in outcomes was similar between groups with the exception of ∆ODI, which demonstrated greater improvement in Medicare patients younger than 65 compared with non-Medicare patients younger than 65.

LEVEL OF EVIDENCE

Level III (treatment).

Trends in Geographic Disparities in Access to Ambulatory Surgery Centers in New York, 2010 to 2018

This cross-sectional analysis evaluates trends in the density, volume, and utilization of ambulatory surgery centers by neighborhood socioeconomic status.

Does Age and Medicare Status Affect Clinical Outcomes in Patients Undergoing Anterior Cervical Discectomy and Fusion?

OBJECTIVE

The objective of this study was to determine if Medicare status and age affect clinical outcomes following anterior cervical discectomy and fusion.

METHODS

Patients who underwent cervical discectomy and fusion between 2014 and 2020 with complete preoperative and 1-year postoperative patient-reported outcome measures (PROMs) were grouped based on Medicare status and age: no Medicare under 65 years (NM < 65), Medicare under 65 years (M < 65), no Medicare 65 years or older (NM ≥ 65), and Medicare 65 years or older (M ≥ 65). Multivariate regression for ΔPROMs (Δ: postoperative minus preoperative) controlled for confounding differences between groups. Significant was set at P < 0.05.

RESULTS

A total of 1288 patients were included, with each group improving in the visual analog score (VAS) Neck (all, P < 0.001), VAS Arm (M < 65: P = 0.003; remaining groups: P < 0.001), and Neck Disability Index (M < 65: P = 0.009; remaining groups: P < 0.001) following surgery. Only M < 65 did not significantly improve in the Physical Component Score (PCS-12) and modified Japanese Orthopaedic Association (mJOA) score (P = 0.256 and P = 0.092, respectively). When comparing patients under 65 years, non-Medicare patients had better preoperative PCS-12 (P < 0.001), Neck Disability Index (P < 0.001), and modified Japanese Orthopaedic Association (P < 0.001), as well as better postoperative values for all PROMs (P < 0.001), but there were no differences in ΔPROMs. Multivariate analysis identified M < 65 to be an independent predictor of decreased improvement in ΔPCS-12 (β = -4.07, P = 0.015), ΔVAS Neck (β = 1.17, P = 0.010), and ΔVAS Arm (β = 1.15, P = 0.025) compared to NM < 65.

CONCLUSIONS

Regardless of age and Medicare status, all patients undergoing cervical discectomy and fusion had significant clinical improvement postoperatively. However, Medicare patients under age 65 have a smaller magnitude of improvement in PROMs.

Private Equity Acquisitions Of Ambulatory Surgical Centers Were Not Associated With Quality, Cost, Or Volume Changes

Ambulatory surgical centers (ASCs) are increasingly being acquired by private equity firms, yet the implications for patients remain understudied. In this study we employed a quasi-experimental difference-in-differences design within an event study framework to assess changes in outcomes associated with the acquisition of ASCs by private equity entities. Using a two-way fixed effects model, we assessed the baseline probability of an unplanned hospital visit, total costs, and total encounters three years preacquisition compared with three years postacquisition in ASCs acquired by private equity versus those acquired by non-private equity entities. We identified ninety-one ASCs acquired by private equity and fifty-seven ASCs acquired by non-private equity entities during the period 2011-14. There was no statistically significant observed change in the probability of an unplanned hospital visit, total costs, or total encounters after acquisition by private equity relative to acquisition by non-private equity entities. When we compared private equity-acquired ASCs with matched ASCs that were never acquired, we also found no statistically significant relative change in the probability of an unplanned hospital visit, total costs, or total encounters. Regulators should ensure that data on private equity acquisitions are transparent and that data are available to track the long-term quality and financial implications of these acquisitions.

Social Disparities in Outpatient and Inpatient Management of Pediatric Supracondylar Humerus Fractures

Socioeconomic status, race, and insurance status are known factors affecting adult orthopaedic surgery care, but little is known about the influence of socioeconomic factors on pediatric orthopaedic care. The purpose of this study was to determine if demographic and socioeconomic related factors were associated with surgical management of pediatric supracondylar humerus fractures (SCHFs) in the inpatient versus outpatient setting. Pediatric patients (<13 years) who underwent surgery for SCHFs were identified in the New York Statewide Planning and Research Cooperative System database from 2009−2017. Inpatient and outpatient claims were identified by International Classification of Diseases-9-Clinical Modification (CM) and ICD-10-CM SCHF diagnosis codes. Claims were then filtered by ICD-9-CM, ICD-10-Procedural Classification System, or Current Procedural Terminology codes to isolate SCHF patients who underwent surgical intervention. Multivariable logistic regression analysis was performed to determine the effect of patient factors on the likelihood of having inpatient management versus outpatient management. A total of 7079 patients were included in the analysis with 4595 (64.9%) receiving inpatient treatment and 2484 (35.1%) receiving outpatient treatment. The logistic regression showed Hispanic (OR: 2.386, p < 0.0001), Asian (OR: 2.159, p < 0.0001) and African American (OR: 2.095, p < 0.0001) patients to have increased odds of inpatient treatment relative to White patients. Injury diagnosis on a weekend had increased odds of inpatient management (OR: 1.863, p = 0.0002). Higher social deprivation was also associated with increased odds of inpatient treatment (OR: 1.004, p < 0.0001). There are disparities among race and socioeconomic status in the surgical setting of SCHF management. Physicians and facilities should be aware of these disparities to optimize patient experience and to allow for equal access to care.

Racial and ethnic differences in pediatric surgery utilization in the United States: A nationally representative cross-sectional analysis

OBJECTIVES

Children of minority background have reduced access to surgery. This study assessed for racial/ethnic differences in surgical utilization by location.

MATERIALS AND METHODS

We conducted a cross-sectional analysis of U.S. children (0-17 years of age) participating in the nationally representative Medical Expenditure Panel Survey (MEPS, 2015-2018). Race/ethnicity was the variable of interest. The primary outcome variables were prevalence rates of surgery defined by location of surgical procedure (inpatient, emergency department, hospital outpatient, and office). Covariates included contextual factors that may influence access to and need for healthcare services, including age, sex, insurance status, residential geographic status, usual source of care, and parental reports of child's physical and mental health. We employed multivariate logistic regression models to assess the relationship between outcomes and race/ethnicity.

RESULTS

The study population included 31,024 children with an overall surgical rate of 4.8%. Adjusted odds of surgery in an ambulatory location were lower for all racial/ethnic minority groups compared to non-Hispanic White counterparts (non-Hispanic Black aOR = 0.3, 95% CI: 0.2-0.5; Hispanic aOR = 0.4, 95% CI: 0.3-0.6; non-Hispanic Asian aOR = 0.2, 95% CI 0.0-0.5 for hospital outpatient surgery; for office-based setting, non-Hispanic Black aOR = 0.4, 95% CI 0.3-0.6; Hispanic aOR = 0.5, 95% CI: 0.4-0.7; non-Hispanic Asian aOR = 0.4; 95% CI 0.3-0.7). No racial/ethnic differences were observed for surgical procedures in inpatient or emergency department locations.

CONCLUSIONS

Staggering differences exist in pediatric surgery utilization patterns by racial/ethnic background, even after adjusting for important contextual factors (income, insurance, health status). Our findings in a nationally representative dataset may suggest systemic barriers related to racial/ethnic background for the pediatric surgical population.

Renal Artery Aneurysms in the Inpatient Setting

BACKGROUND

The risk of rupture of renal artery aneurysms (RAAs) remains undefined. A recent paper from the Vascular Low-Frequency Disease Consortium (VLFDC) identified only 3 ruptures in 760 patients. However, over 80% of patients in the VLFDC study were treated at large academic centers, which may not reflect the pattern of care of RAAs nationwide. Thus, the purpose of this study was to evaluate the pattern of nonelective versus elective surgery requiring inpatient admission for RAAs, including nephrectomies, and their outcomes using a national database.

METHODS

The National Inpatient Sample (NIS) database from 2012 to 2018 was utilized. Patients with a primary diagnosis of RAAs were identified using ICD-9 and ICD-10 codes. Ruptured RAAs (rRAAs) were identified utilizing surrogate ICD codes. The primary outcome variables for this study were proportion of RAAs requiring non-elective surgery and in-hospital mortality.

RESULTS

A total of 590 inpatient admissions for RAA were identified with 554 procedures at 467 hospitals across the country. Of the 590 inpatient admissions, 380 (64.4%) admissions were deemed nonelective. There was an increasing proportion of nonelective admissions over the study period. The overall rate of nephrectomies was 7.1% (n = 42). In-hospital mortality rate for the cohort was 1.4% (n = 8) with no differences in in-hospital mortality in the elective versus nonelective setting (1.0% vs. 1.6%; P = 0.718). In the nonelective setting, patients requiring a nephrectomy (n = 23) had significantly higher rates of in-hospital mortality compared those not requiring a nephrectomy (8.7% vs. 1.1%, P = 0.045). rRAA (n = 50) patients had significantly higher in-hospital mortality compared to the remainder of the cohort (6.0% vs. 0.9%, P = 0.024). rRAA patients were also more likely to undergo a nephrectomy compared to the remainder of the cohort (16.0% vs. 6.3%, P = 0.019).

CONCLUSIONS

These data demonstrate that treatment of RAAs are primarily done in the nonelective setting with a high proportion of ruptures, which could continue to rise as the threshold for repair has decreased.

Long-term survival in elderly women receiving chemotherapy for non-metastatic breast cancer: a population-based analysis

BACKGROUND

Older women are poorly represented in trials evaluating chemotherapy for breast cancer (BC). This study aimed to describe survival and associated factors among elderly women receiving chemotherapy for non-metastatic BC.

METHODS

This was a population-based cohort study including women ≥ 70 years old diagnosed with invasive, non-metastatic BC from 2010 to 2017 in SEER. Among those who received chemotherapy, overall survival (OS) was determined using Kaplan-Meier curves and hazard ratios were reported with 95% confidence intervals (CIs). Adjustment was made for available confounders. Co-morbidity is not available in SEER. BC-specific survival (BCSS) and subdistribution hazard ratios were determined using competing risks analysis.

RESULTS

The cohort consisted of 109,239 women aged 70+, of whom 17,961 (16%) received chemotherapy. Chemotherapy patients were younger (median 73.0 years vs. 77.0), had more advanced disease (25% stage III vs. 5.2%), and were more likely to receive mastectomy (50% vs. 33%). Among chemotherapy patients, 5-year OS was 77.8% (95% CI 76.9-78.6%), and for women 80+ was 60.2% (95% CI 57.5-63.1%). More recent diagnoses, no previous history of cancer, and receipt of radiotherapy were all associated with improved BCSS. Conversely, older age, higher tumour grade, advanced stage, and human epidermal growth factors receptor (HER)2 negative tumours were associated with worse BCSS. 56% of deaths were due to BC, and women aged 80+ had worse BCSS compared to those aged 70-79 (adjusted sdHR 1.62, 95% CI 1.43-1.84).

CONCLUSIONS

Elderly women with advanced disease can achieve good survival after chemotherapy for non-metastatic BC. Those with HER2+ disease have superior survival, reinforcing benefit in this population.

Disparities in Index of Care for Otolaryngologic Procedures Performed in Ambulatory and Inpatient Settings

OBJECTIVE

To compare the same surgical procedure performed in ambulatory and inpatient settings to determine the demographics associated with this selection, the differences in 30-day revisit rates, and the total 30-day cost of care.

STUDY DESIGN

Retrospective cohort analysis.

SETTING

Ambulatory and inpatient centers in Florida, New York, and Maryland.

METHODS

The Healthcare Cost and Utilization Project, the State Ambulatory Surgery and Services Database, and the State Inpatient Database were used to identify patients undergoing commonly performed otolaryngologic procedures in 2016. The State Emergency Department Database and State Inpatient Database were used to identify 30-day revisits.

RESULTS

A total of 55,311 patients underwent an otolaryngologic procedure: 51,136 (92.4%) ambulatory and 4175 (7.6%) inpatient. Adjusted odds of receiving care in the ambulatory setting was significantly lower for Black patients (odds ratio, 0.69 [95% CI, 0.55-0.85]; P = .001) and nonspecified other races (odds ratio, 0.71 [95% CI, 0.52-0.95]; P = .001) as compared with White patients. Women had 1.16-higher adjusted odds of undergoing a procedure in the ambulatory setting (95% CI, 1.05-1.29; P = .005). Insurance status and income were associated with location of care in the subcategorization of head and neck surgery. Adjusted inpatient procedure costs were significantly more than ambulatory (median, $59,112 vs $14,899); 30-day adjusted costs were $71,333.07 (95% CI, $56,223.99-$86,42.15; P < .001) more expensive for inpatient procedures vs ambulatory; and the adjusted 30-day odds of revisit were 2.23 times greater (95% CI, 1.44-3.44; P < .001) for ambulatory surgery across all procedures.

CONCLUSIONS

Disparities exist in the use of ambulatory settings to provide otolaryngologic surgery. Additional research is required to ensure equitable triaging of surgical care setting.

The impact of age and nodal status on variations in oncotype DX testing and adjuvant treatment

Oncotype DX (ODX) recurrence score (RS) is a validated tool to guide the use of adjuvant chemotherapy (AC) in hormone receptor+/HER2- breast cancer. In this analysis, we examine (1) characteristics associated with ODX testing and (2) the association between ODX RS and receipt of AC across age and nodal status. Women with HR+/HER2–, early-stage (T1-2, N0-1) breast cancers from 2010–2017 in the National Cancer Database were included. 530,125 met inclusion and 255,971 received ODX testing. Older women were less likely to receive testing; however, nodal positivity increased use of testing. High ODX RS was associated with increased mortality, though the association was not consistent across age and was most strongly associated with mortality among younger, node-negative women. Older women with high ODX RS, regardless of nodal status, were less likely to receive AC. Clinicians may be employing ODX RS to support treatment decisions against the receipt of AC.

Outpatient Operative Management of Pediatric Supracondylar Humerus Fractures: An Analysis of Frequency, Complications, and Cost From 2009 to 2018

BACKGROUND

In an effort to increase the value of health care in the United States, there has been increased focus on shifting certain procedures to an outpatient setting. While pediatric supracondylar humerus fractures (SCHFs) have traditionally been treated in an inpatient setting, recent studies have investigated the safety and efficiency of outpatient surgery for these injuries. This retrospective study aims to examine ongoing trends of outpatient surgical care for SCHFs, examine the safety and complication rates of these procedures, and investigate the potential cost-savings from this shift in care.

METHODS

Pediatric patients less than 13 years old who underwent surgery for closed SCHF from 2009 to 2018 were identified using International Classification of Diseases-9/10 Clinical Modification and Procedural Classification System codes in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Linear regression was used to assess the shift in proportion of outpatient surgical management of these injuries over time. Multivariable Cox proportional hazards regression was used to compare return to emergency department (ED) visit, readmission, reoperation, and other adverse events. A 2-sample t test was performed on the average charge amount per claim for inpatient versus outpatient surgery.

RESULTS

A total of 8488 patients were included in the analysis showing there was a statistically significant shift towards outpatient management between 2009 (23% outpatient) and 2018 (59% outpatient) (P<0.0001). Relative to inpatient surgical management, outpatient surgical management had lower rates of return ED visits at 1 month (hazard ratio: 0.744, P=0.048). All other adverse events compared across inpatient and outpatient surgical management were not significantly different. The median amount billed per claim for inpatient surgeries was significantly higher than for outpatient surgeries ($16,097 vs. $9,752, P<0.0001). White race, female sex, and weekday ED visit were associated with increased rate of outpatient management.

CONCLUSIONS

This study demonstrates the trend of increasing outpatient surgical management of pediatric SCHF from 2009 to 2018. The increased rate of outpatient management has not been associated with elevated complication rates but is associated with significantly reduced health care charges.

LEVEL OF EVIDENCE

Level III-retrospective cohort.

Race-Based Differences in the Utilization and Timing of Secondary Cleft Procedures in the United States

Primary CL/P repair, revisions, and secondary procedures-cleft rhinoplasty, speech surgery, and alveolar bone grafting (ABG)-performed from 2014-2018 were identified from the Pediatric National Surgical Quality Improvement Program (NSQIP) database. Utilization estimates were derived via univariable and multivariable logistic regression. A Kruskal-Wallis rank-sum test and multivariable linear regression were used to assess differences in timing for each procedure cohort.

The primary outcome measures were the odds of a patient being a certain race/ethnicity, and the age at which patients of different race/ethnicity receive surgery.

There were 23 780 procedures analyzed. After controlling for sex, diagnosis, and functional status, there were significant differences in utilization estimates across procedure groups. Primarily, utilization was lowest in patient who were Black for cleft rhinoplasty (OR = 0.70, P = .023), ABG (OR = 0.44, P < .001) and speech surgery (OR = 0.57, P = .012), and highest in patients who were Asian patients in all surgery cohorts (OR 2.05-4.43). Timing of surgery also varied by race, although differences were minimal.

CONCLUSIONS

Estimates of utilization and timing of secondary cleft procedures varied by race, particularly among patients who were Black (poor utilization) or Asian (high utilization). Further studies should identify the causes and implications of underutilized and/or delayed cleft care.

Evaluation of the Merit-Based Incentive Payment System and Surgeons Caring for Patients at High Social Risk

Importance

The latest step in the Centers for Medicaid & Medicare transformation to pay-for-value is the Medicare Merit-Based Incentive Payment System (MIPS). Value-based payment designs often do not account for uncaptured clinical status and social determinants of health in patients at high social risk, and the consequences for clinicians and patients associated with their use have not been explored.

Objective

To evaluate MIPS scoring of surgeons caring for patients at high social risk to determine whether this implementation threatens disadvantaged patients' access to surgical care.

Design, Setting, and Participants

A retrospective cohort study of US general surgeons participating in MIPS during its first year in outpatient surgical practices across the US and territories. The study was conducted from September 1, 2020, to May 1, 2021. Data were analyzed from November 1, 2020, to March 30, 2021 (although data were collected during the 2017 calendar year and reported ahead of 2019 payment adjustments).

Main Outcomes and Measures

Characteristics of surgeons participating in MIPS, overall MIPS score assigned to clinician. and practice-level disadvantage measures. The MIPS scores can range from 0 to 100. For the first year, a score of less than 3 led to negative payment adjustment; a score of greater than 3 but less than 70 to a positive adjustment; and a score of 70 or higher to the exceptional performance bonus.

Results

Of 20 593 general surgeons, 10 252 participated in the first year of MIPS. Surgeons with complete patient data (n = 9867) were evaluated and a wide range of dual-eligible patient caseloads from 0% to 96% (mean [SD], 27.1% [14.5%]) was identified. Surgeons in the highest quintile of dual eligibility cared for a Medicare patient caseload ranging from 37% to 96% dual eligible for Medicare and Medicaid. Surgeons caring for the patients at highest social risk had the lowest final mean (SD) MIPS score compared with the surgeons caring for the patients at least social risk (66.8 [37.3] vs 71.2 [35.9]; P < .001).

Conclusions and Relevance

Results of this cohort study suggest that implementation of MIPS value-based care reimbursement without adjustment for caseload of patients at high social risk may penalize surgeons who care for patients at highest social risk.

Disparities in Utilization of Ambulatory Cholecystectomy: Results From Three States

BACKGROUND

Inpatient cholecystectomy is associated with higher cost and morbidity relative to ambulatory cholecystectomy, yet the latter may be underutilized by minority and underinsured patients. The purpose of this study was to examine the effects of race, income, and insurance status on receipt of and outcomes following ambulatory cholecystectomy.

MATERIALS AND METHODS

Retrospective observational cohort study of patients 18-89 undergoing cholecystectomy for benign indications in Florida, Iowa, and New York, 2011-2014 using administrative databases. The primary outcome of interest was odds of having ambulatory cholecystectomy; secondary outcomes included intraoperative and postoperative complications, and 30-day unplanned admissions following ambulatory cholecystectomy.

RESULTS

Among 321,335 cholecystectomies, 190,734 (59.4%) were ambulatory and 130,601 (40.6%) were inpatient. Adjusting for age, sex, insurance, income, residential location, and comorbidities, the odds of undergoing ambulatory versus inpatient cholecystectomy were significantly lower in black (aOR = 0.71, 95% CI [0.69, 0.73], P< 0.001) and Hispanic (aOR = 0.71, 95% CI [0.69, 0.72], P< 0.001) patients compared to white patients, and significantly lower in Medicare (aOR = 0.77, 95% CI [0.75, 0.80] P < 0.001), Medicaid (aOR = 0.56, 95% CI [0.54, 0.57], P< 0.001) and uninsured/self-pay (aOR = 0.28, 95% CI [0.27, 0.28], P< 0.001) patients relative to privately insured patients. Patients with Medicaid and those classified as self-pay/uninsured had higher odds of postoperative complications and unplanned admission as did patients with Medicare compared to privately insured individuals.

CONCLUSIONS

Racial and ethnic minorities and the underinsured have a higher likelihood of receiving inpatient as compared to ambulatory cholecystectomy. The higher incidence of postoperative complications in these patients may be associated with unequal access to ambulatory surgery.

High Social Vulnerability and "Textbook Outcomes" after Cancer Operation

BACKGROUND

The effect of community-level factors on surgical outcomes has not been well examined. We sought to characterize differences in "textbook outcomes" (TO) relative to social vulnerability among Medicare beneficiaries who underwent operations for cancer.

METHODS

Individuals who underwent operations for lung, esophageal, colon, or rectal cancer between 2013 and 2017 were identified using the Medicare database, which was merged with the CDC's Social Vulnerability Index (SVI). TO was defined as surgical episodes with the absence of complications, extended length of stay, readmission, and mortality. The association of SVI and TO was assessed using mixed-effects logistic regression.

RESULTS

Among 203,800 patients (colon, n = 113,929; lung, n = 70,642; rectal, n = 14,849; and esophageal, n = 4,380), median age was 75 years (interquartile range 70 to 80 years) and the overwhelming majority of patients was White (n = 184,989 [90.8%]). The overall incidence of TO was 56.1% (n = 114,393). The incidence of complications (low SVI: 21.5% vs high SVI: 24.0%) and 90-day mortality (low SVI: 7.0% vs high SVI: 8.4%) were higher among patients from highly vulnerable neighborhoods (both, p < 0.05). In turn, there were lower odds of achieving TO among high-vs low-SVI patients (odds ratio 0.83; 95% CI, 0.78 to 0.87). Although high-SVI White patients had 10% lower odds (95% CI, 0.87 to 0.93) of achieving TO, high-SVI non-White patients were at 22% lower odds (95% CI, 0.71 to 0.85) of postoperative TO. Compared with low-SVI White patients, high-SVI minority patients had 47% increased odds of an extended length of stay, 40% increased odds of a complication, and 23% increased odds of 90-day mortality (all, p < 0.05).

CONCLUSIONS

Only roughly one-half of Medicare beneficiaries achieved the composite optimal TO quality metric. Social vulnerability was associated with lower attainment of TO and an increased risk of adverse postoperative surgical outcomes after several common oncologic procedures. The effect of high SVI was most pronounced among minority patients.