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Das A, Vazquez S, Stein A, Greisman JD, Ng C, Ming T, Vaserman G, Spirollari E, Naftchi AF, Dominguez JF, Hanft SJ, Houten J, Kinon MD. Disparities in anterior cervical discectomy and fusion provision and outcomes for cervical stenosis. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 14:100217. [PMID: 37214264 PMCID: PMC10192645 DOI: 10.1016/j.xnsj.2023.100217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/28/2023] [Accepted: 04/03/2023] [Indexed: 05/24/2023]
Abstract
Background Disparities in neurosurgical care have emerged as an area of interest when considering the impact of social determinants on access to health care. Decompression via anterior cervical discectomy and fusion (ACDF) for cervical stenosis (CS) may prevent progression towards debilitating complications that may severely compromise one's quality of life. This retrospective database analysis aims to elucidate demographic and socioeconomic trends in ACDF provision and outcomes of CS-related pathologies. Methods The Healthcare Cost and Utilization Project National Inpatient Sample database was queried between 2016 and 2019 using International Classification of Diseases 10th edition codes for patients undergoing ACDF as a treatment for spinal cord and nerve root compression. Baseline demographics and inpatient stay measures were analyzed. Results Patients of White race were significantly less likely to present with manifestations of CS such as myelopathy, plegia, and bowel-bladder dysfunction. Meanwhile, Black patients and Hispanic patients were significantly more likely to experience these impairments representative of the more severe stages of the degenerative spine disease process. White race conferred a lesser risk of complications such as tracheostomy, pneumonia, and acute kidney injury in comparison to non-white race. Insurance by Medicaid and Medicare conferred significant risks in terms of more advanced disease prior to intervention and negative inpatient. Patients in the highest quartile of median income consistently fared better than patients in the lowest quartile across almost every aspect ranging from degree of progression at initial presentation to incidence of complications to healthcare resource utilization. All outcomes for patients age > 65 were worse than patients who were younger at the time of the intervention. Conclusions Significant disparities exist in the trajectory of CS and the risks associated with ACDF amongst various demographic cohorts. The differences between patient populations may be reflective of a larger additive burden for certain populations, especially when considering patients' intersectionality.
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Affiliation(s)
- Ankita Das
- School of Medicine, New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY 10595, United States
| | - Sima Vazquez
- School of Medicine, New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY 10595, United States
| | - Alan Stein
- Department of Neurosurgery, Westchester Medical Center, 100 Woods Road, Valhalla, NY 10595, United States
| | - Jacob D. Greisman
- School of Medicine, New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY 10595, United States
| | - Christina Ng
- School of Medicine, New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY 10595, United States
| | - Tiffany Ming
- School of Medicine, New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY 10595, United States
| | - Grigori Vaserman
- School of Medicine, New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY 10595, United States
| | - Eris Spirollari
- School of Medicine, New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY 10595, United States
| | - Alexandria F. Naftchi
- School of Medicine, New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY 10595, United States
| | - Jose F. Dominguez
- Department of Neurosurgery, Westchester Medical Center, 100 Woods Road, Valhalla, NY 10595, United States
| | - Simon J. Hanft
- Department of Neurosurgery, Westchester Medical Center, 100 Woods Road, Valhalla, NY 10595, United States
| | - John Houten
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY 10029, United States
| | - Merritt D. Kinon
- Department of Neurosurgery, Westchester Medical Center, 100 Woods Road, Valhalla, NY 10595, United States
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Rich BJ, Kwon D, Soni YS, Bell JB, John D, Azzam G, Mellon EA, Yechieli R, Meshman J, Abramowitz MC, Marques J, Benjamin CG, Komotar RJ, Ivan M, Diwanji T. Survival and Yield of Surveillance Imaging in Long-Term Survivors of Brain Metastasis Treated with Stereotactic Radiosurgery. World Neurosurg 2022; 167:e738-e746. [PMID: 36028107 DOI: 10.1016/j.wneu.2022.08.079] [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: 08/03/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVES The optimal frequency of surveillance brain magnetic resonance imaging (MRI) in long-term survivors with brain metastases after stereotactic radiosurgery (SRS) is unknown. Our aim was to identify the optimal frequency of surveillance imaging in long-term survivors with brain metastases after SRS. METHODS Eligible patients were identified from a cohort treated with SRS definitively or postoperatively at our institution from 2014 to 2019 with no central nervous system (CNS) failure within 12 months from SRS. Time to CNS disease failure diagnosis and cost per patient were estimated using theoretical MRI schedules of 2, 3, 4, and 6 months starting 1 year after SRS until CNS failure. Time to diagnosis was calculated from the date of CNS progression to the theoretical imaging date on each schedule. RESULTS This cohort included 55 patients (median follow-up from SRS: 2.48 years). During the study period, 20.0% had CNS disease failure (median: 2.26 years from SRS treatment). In this cohort, a theoretical 2-month, 3-month, 4-month, and 6-month MRI brain surveillance schedule produced a respective estimated time to diagnosis of CNS disease failure of 1.11, 1.74, 1.65, and 3.65 months. The cost of expedited diagnosis for the cohort (dollars/month) for each theoretical imaging schedule compared with a 6-month surveillance schedule was $6600 for a 2-month protocol, $4496 for a 3-month protocol, and $2180 for a 4-month protocol. CONCLUSIONS Based on cost-benefit, a 4-month MRI brain schedule should be considered in patients with metastatic disease to the brain treated definitively or postoperatively with SRS without evidence of CNS recurrence at 1 year.
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Affiliation(s)
- Benjamin J Rich
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA.
| | - Deukwoo Kwon
- Department of Public Health Sciences, Biostatistics and Bioinformatics Shared Resource, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Yash S Soni
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jonathan B Bell
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Danny John
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Gregory Azzam
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eric A Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Raphael Yechieli
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jessica Meshman
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Matthew C Abramowitz
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Joao Marques
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Carolina G Benjamin
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ricardo J Komotar
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Michael Ivan
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Tejan Diwanji
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
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Rodrigues A, Li G, Bhambhvani H, Hayden-Gephart M. Socioeconomic Disparities in Brain Metastasis Survival and Treatment: A Population-Based Study. World Neurosurg 2022; 158:e636-e644. [PMID: 34785360 PMCID: PMC9363111 DOI: 10.1016/j.wneu.2021.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/06/2021] [Accepted: 11/08/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE In the present study, we used a validated socioeconomic status (SES) index and population-based registry to identify and quantify the impact of SES on access to treatment and overall survival for patients diagnosed with synchronous brain metastases. METHODS The Surveillance, Epidemiology, and End Results database was used to extract all patients between 2010 and 2016 with brain metastases at initial presentation. SES was stratified into tertiles and quintiles using the validated Yost index. Multivariable logistic regressions were used to evaluate the impact of demographic, tumor, and socioeconomic covariates on receipt of radiotherapy and chemotherapy. Kaplan-Meier curves were used to estimate survival. RESULTS Between 2010 and 2016, 35,595 patients presented with brain metastases at the time of primary cancer diagnosis. Most patients received radiation and/or chemotherapy as part of the initial course of their treatment; 71.6% (n = 25,484) were irradiated while 54.4% (n = 19,371) received chemotherapy and 44.9% (n = 15,984) received chemoradiation. Patients in the highest Yost tertile and quintile experienced longer overall survival (P < 0.001). Additionally, multivariable logistic regression revealed that the lowest Yost quintile was significantly less likely to receive either radiation (adjusted OR: 0.82; 95% confidence interval: 0.75-0.89; P < 0.001) or chemotherapy (adjusted OR: 0.62; 95% confidence interval: 0.58-0.67; P < 0.001). CONCLUSIONS In a large, population-based analysis of brain metastasis patients, we found significant differences in treatment access and mild survival differences along socioeconomic strata. More specifically, patients in lower SES tiers suffered worse outcomes and received radiation and chemotherapy less frequently than patients in higher tiers, even after accounting for other tumor- and demographic-related information.
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Systematic Review of Racial, Socioeconomic, and Insurance Status Disparities in Neurosurgical Care for Intracranial Tumors. World Neurosurg 2021; 158:38-64. [PMID: 34710578 DOI: 10.1016/j.wneu.2021.10.126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The impact of race, socioeconomic status (SES), insurance status, and other social metrics on the outcomes of patients with intracranial tumors has been reported in several studies. However, these findings have not been comprehensively summarized. METHODS We conducted a PRISMA systematic review of all published articles between 1990 and 2020 that analyzed intracranial tumor disparities, including race, SES, insurance status, and safety-net hospital status. Outcomes measured include access, standards of care, receipt of surgery, extent of resection, mortality, complications, length of stay (LOS), discharge disposition, readmission rate, and hospital charges. RESULTS Fifty-five studies were included. Disparities in mortality were reported in 27 studies (47%), showing minority status and lower SES associated with poorer survival outcomes in 14 studies (52%). Twenty-seven studies showed that African American patients had worse outcomes across all included metrics including mortality, rates of surgical intervention, extent of resection, LOS, discharge disposition, and complication rates. Thirty studies showed that privately insured patients and patients with higher SES had better outcomes, including lower mortality, complication, and readmission rates. Six studies showed that worse outcomes were associated with treatment at safety-net and/or low-volume hospitals. The influence of Medicare or Medicaid status, or inequities affecting other minorities, was less clearly delineated. Ten studies (18%) were negative for evidence of disparities. CONCLUSIONS Significant disparities exist among patients with intracranial tumors, particularly affecting patients of African American race and lower SES. Efforts at the hospital, state, and national level must be undertaken to identify root causes of these issues.
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Dambrino RJ, Zuckerman SL, Guidry BS, Domenico HJ, Thompson RC, Galloway MB, Pichert JW, Cooper WO. Do neurosurgeons receive more patient complaints than other physicians? Describing who is most at risk and how we can improve. J Neurosurg 2021; 134:1990-1997. [DOI: 10.3171/2020.4.jns20870] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The number of unsolicited patient complaints (UPCs) about surgeons correlates with surgical complications and malpractice claims. Using a large, national patient complaint database, the authors sought to do the following: 1) compare the rates of UPCs for neurosurgeons to those for other physicians, 2) analyze the risk of UPCs with individual neurosurgeon characteristics, and 3) describe the types of UPCs made about neurosurgeons.
METHODS
Patient and family complaint reports among 36,265 physicians, including 423 neurosurgeons, 8292 other surgeons, and 27,550 nonsurgeons who practiced at 33 medical centers (22 academic and 11 regional) from January 1, 2014, to December 31, 2017, were coded with a previously validated Patient Advocacy Reporting System (PARS) algorithm.
RESULTS
Among 423 neurosurgeons, 93% were male, and most (71%) practiced in academic medical centers. Neurosurgical subspecialties included general practice (25%), spine (25%), tumor (16%), vascular (13%), functional (10%), and pediatrics (10%). Neurosurgeons had more average total UPCs per physician (8.68; 95% CI 7.68–9.67) than nonsurgeons (3.40; 95% CI 3.33–3.47) and other surgeons (5.01; 95% CI 4.85–5.17; p < 0.001). In addition, a significantly higher percentage of neurosurgeons received at least one UPC (71.6%; 95% CI 67.3%–75.9%) than did nonsurgeons (50.2%; 95% CI 49.6%–50.8%) and other surgeons (58.2%; 95% CI 57.1%–59.3%; p < 0.001). Factors most associated with increased average UPCs were younger age, measured as median medical school graduation year (1990.5 in the 0-UPC group vs 1993 in the 14+-UPC group, p = 0.009) and spine subspecialty (13.4 mean UPCs in spine vs 7.9 mean UPCs in other specialties, 95% CI 2.3–8.5, p < 0.001). No difference in complaints was seen in those who graduated from non-US versus US medical schools (p = 0.605). The most common complaint types were related to issues surrounding care and treatment, communication, and accessibility, each of which was significantly more common for neurosurgeons than other surgical specialties (p < 0.001).
CONCLUSIONS
Neurosurgeons were more likely to generate UPCs than other surgical specialties, and almost 3 out of 4 neurosurgeons (71.6%) had at least one UPC during the study period. Prior studies have shown that feedback to physicians about behavior can result in fewer UPCs. These results suggest that neurosurgeons have opportunities to reduce complaints and potentially improve the overall quality of care delivered.
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Affiliation(s)
| | | | | | | | | | | | | | - William O. Cooper
- 4Center for Patient and Professional Advocacy, and
- 5Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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Tang OY, Rivera Perla KM, Lim RK, Weil RJ, Toms SA. The impact of hospital safety-net status on inpatient outcomes for brain tumor craniotomy: a 10-year nationwide analysis. Neurooncol Adv 2021; 3:vdaa167. [PMID: 33506205 PMCID: PMC7813162 DOI: 10.1093/noajnl/vdaa167] [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] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Outcome disparities have been documented at safety-net hospitals (SNHs), which disproportionately serve vulnerable patient populations. Using a nationwide retrospective cohort, we assessed inpatient outcomes following brain tumor craniotomy at SNHs in the United States. Methods We identified all craniotomy procedures in the National Inpatient Sample from 2002–2011 for brain tumors: glioma, metastasis, meningioma, and vestibular schwannoma. Safety-net burden was calculated as the number of Medicaid plus uninsured admissions divided by total admissions. Hospitals in the top quartile of burden were defined as SNHs. The association between SNH status and in-hospital mortality, discharge disposition, complications, hospital-acquired conditions (HACs), length of stay (LOS), and costs were assessed. Multivariate regression adjusted for patient, hospital, and severity characteristics. Results 304,719 admissions were analyzed. The most common subtype was glioma (43.8%). Of 1,206 unique hospitals, 242 were SNHs. SNH admissions were more likely to be non-white (P < .001), low income (P < .001), and have higher severity scores (P = .034). Mortality rates were higher at SNHs for metastasis admissions (odds ratio [OR] = 1.48, P = .025), and SNHs had higher complication rates for meningioma (OR = 1.34, P = .003) and all tumor types combined (OR = 1.17, P = .034). However, there were no differences at SNHs for discharge disposition or HACs. LOS and hospital costs were elevated at SNHs for all subtypes, culminating in a 10% and 9% increase in LOS and costs for the overall population, respectively (all P < .001). Conclusions SNHs demonstrated poorer inpatient outcomes for brain tumor craniotomy. Further analyses of the differences observed and potential interventions to ameliorate interhospital disparities are warranted.
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Affiliation(s)
- Oliver Y Tang
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Krissia M Rivera Perla
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Rachel K Lim
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Steven A Toms
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
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Increased 30-day readmission rate after craniotomy for tumor resection at safety net hospitals in small metropolitan areas. J Neurooncol 2020; 148:141-154. [PMID: 32346836 DOI: 10.1007/s11060-020-03507-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/18/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Unplanned readmission of post-operative brain tumor patients is often attributed to hospital and patient characteristics and is associated with higher mortality and cost. Previous studies demonstrate multiple patient outcome disparities in safety net hospitals (SNHs) when compared to non-SNHs. This study uses the Nationwide Readmissions Database (NRD) to determine if initial brain tumor resection at SNHs is associated with increased 30-day non-elective readmission rates. METHODS Patients with benign or malignant primary or metastatic brain tumor undergoing craniotomy for surgical resection were retrospectively identified in the NRD from 2010 to 2014. SNHs were defined as hospitals with Medicaid and uninsured patient burden in the top quartile. Descriptive and multivariate analyses employing survey-adjusted logistic regression evaluated patient and hospital level factors influencing 30-day readmissions. RESULTS During the study period, 83,367 patients met inclusion criteria. 44.7% of patients had a benign tumor, and 55.3% had a malignant tumor. Secondary CNS neoplasm (5.99%), post-operative infection (5.96%), and septicemia (4.26%) caused most readmissions within 30 days. Patients had increased unplanned readmission rates if they underwent craniotomy for tumor resection at a SNH in a small metropolitan area (OR 1.11, 95% CI 1.02-1.21, p = 0.01), but not at a SNH in a large metropolitan area (OR 0.99, 95% CI 0.93-1.05, p = 0.73). CONCLUSION This finding may reflect differences in access to care and disparities in neurosurgical resources between small and large metropolitan areas. Inequities in expertise and capacity are relevant as surgical volume was also related to readmission rates. Further studies may be warranted to address such disparities.
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Cyprich J, Pangal DJ, Rutkowski M, Donoho DA, Shiroishi M, Jason Liu CS, Carmichael JD, Zada G. Comparative preoperative characteristics and postoperative outcomes at a private versus a safety-net hospital following endoscopic endonasal transsphenoidal resection of pituitary adenomas. J Neurosurg 2020; 134:742-749. [PMID: 32109866 DOI: 10.3171/2019.12.jns192506] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sociodemographic disparities in health outcomes are well documented, but the effects of such disparities on preoperative presentation of pituitary adenomas (PA) and surgical outcomes following resection are not completely understood. In this study the authors sought to compare the preoperative clinical characteristics and postoperative outcomes in patients undergoing PA resection at a private hospital (PH) versus a safety-net hospital (SNH). METHODS The authors conducted a retrospective review over a 36-month period of patients with PAs who underwent endoscopic endonasal transsphenoidal surgery performed by the same attending neurosurgeon at either a PH or an SNH at a single academic medical institution. RESULTS A total of 92 PH patients and 69 SNH patients were included. SNH patients were more likely to be uninsured or have Medicaid (88.4% vs 10.9%, p < 0.0001). A larger percentage of SNH patients were Hispanic (98.7% vs 32.6% p < 0.0001), while PH patients were more likely to be non-Hispanic white (39.1% vs 4.3%, p < 0.0001). SNH patients had a larger mean PA diameter (26.2 vs 22.4 mm, p = 0.0347) and a higher rate of bilateral cavernous sinus invasion (13% vs 4.3%, p = 0.0451). SNH patients were more likely to present with headache (68.1% vs 45.7%, p = 0.0048), vision loss (63.8% vs 35.9%, p < 0.0005), panhypopituitarism (18.8% vs 4.3%, p = 0.0031), and pituitary apoplexy (18.8% vs 7.6%, p = 0.0334). Compared to PH patients, SNH patients were as likely to undergo gross-total resection (73.9% vs 76.1%, p = 0.7499) and had similar rates of postoperative improvement in headache (80% vs 89%, p = 0.14) and vision (82% vs 84%, p = 0.74), but had higher rates of postoperative panhypopituitarism (23% vs 10%, p = 0.04) driven by preoperative endocrinopathies. Although there were no differences in tumor recurrence or progression, loss to follow-up was seen in 7.6% of PH versus 18.6% (p = 0.04) of SNH patients. CONCLUSIONS Patients presenting to the SNH were more often uninsured or on Medicaid and presented with larger, more advanced pituitary tumors. SNH patients were more likely to present with headaches, vision loss, and apoplexy, likely translating to greater improvements in headache and vision observed after surgery. These findings highlight the association between medically underserved populations and more advanced disease states at presentation, and underscore the likely role of academic tertiary multidisciplinary care teams and endoscopic PA resection in somewhat mitigating sociodemographic factors known to portend poorer outcomes, though longer-term follow-up is needed to confirm these findings.
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Affiliation(s)
| | | | | | | | - Mark Shiroishi
- 2Division of Neuroradiology, Department of Radiology, and
| | | | - John D Carmichael
- 3Division of Endocrinology, Department of Medicine, Keck School of Medicine, University of Southern California; and.,4USC Pituitary Center, Los Angeles, California
| | - Gabriel Zada
- 1Department of Neurosurgery.,4USC Pituitary Center, Los Angeles, California
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9
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Factors Leading to Decreased Rates of Immediate Postmastectomy Reconstruction. J Surg Res 2019; 238:207-217. [PMID: 30772679 DOI: 10.1016/j.jss.2019.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 12/19/2018] [Accepted: 01/04/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study was performed to determine if there was a difference in immediate breast reconstruction (IBR) rates between our public hospital and private cancer center, which share a common faculty with a consistent management philosophy in multidisciplinary care. We investigated the factors affecting postmastectomy reconstruction and IBR rates. MATERIALS AND METHODS We retrospectively identified women with clinical stage I-II breast cancer who underwent mastectomy at our public hospital, Los Angeles County Medical Center, and our private cancer center, Keck Hospital of USC/Norris Comprehensive Cancer Center. Univariate and multivariate analyses were performed to study predictors of IBR and any breast reconstruction. RESULTS Of 293 mastectomy patients, the rate of any breast reconstruction at the private cancer (56.6%) center was higher than that at the public hospital (36.2%). IBR rates for the private cancer center (93.6%) and for patients with private insurance were higher than for the public hospital (40.8%) and likewise for those without insurance (86.7% versus 45.5%). In a multivariate analysis, the odds of IBR at our private cancer center were 22.96 times higher than that at our public hospital. Age >50 y and radiotherapy were independent predictive factors associated with less likelihood of any breast reconstruction. CONCLUSIONS Patients at the public hospital had a much lower rate of breast reconstruction than the private cancer center patients, even after controlling for stage and the team of treating physicians. Our results showed that older age and radiotherapy affect rates of breast reconstruction, as do hospital system and insurance status.
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Perlow HK, Ramey SJ, Cassidy V, Kwon D, Farnia B, Nicolli E, Samuels MA, Freedman L, Elsayyad N, Yechieli R, Samuels SE. Disparities in adherence to head and neck cancer follow-up guidelines. Laryngoscope 2018; 129:2303-2308. [PMID: 30582620 DOI: 10.1002/lary.27676] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVES In this study, we aim to determine the frequency of adherence to National Comprehensive Cancer Network follow-up guidelines in a population of head and neck cancer patients who received curative treatment. We will also assess the impact of race, ethnicity, socioeconomic status, and treatment setting on utilization of follow-up care. METHODS This study included patients with biopsy-proven, nonmetastatic oropharyngeal or laryngeal cancer treated with radiotherapy between January 1, 2014, and June 30, 2016, at a safety-net hospital or adjacent private academic hospital. Components of follow-up care analyzed included an appointment with a surgeon or radiation oncologist within 3 months and posttreatment imaging of the primary site within 6 months. Univariable and multivariable analyses were conducted using a logistic regression model to estimate odds ratios and corresponding 95% confidence intervals. RESULTS Two hundred and thirty-four patients were included in this study. Of those, 88.8% received posttreatment imaging of the primary site within 6 months; 88.5% attended a follow-up appointment with a radiation oncologist within 3 months; and 71.1% of patients attended a follow-up appointment with a surgeon within 3 months. On multivariable analysis, private academic hospital treatment versus safety-net hospital treatment was associated with increased utilization of both surgical and radiation oncology follow-up. Non-Hispanic black (NHB) patients, Hispanic patients, and those with a low socioeconomic status were also less likely to receive follow-up. CONCLUSION Safety-net hospital treatment, socioeconomic status, Hispanic ethnicity, and NHB race were associated with decreased follow-up service utilization. Quality improvement initiatives are needed to reduce these disparities. LEVEL OF EVIDENCE 2b Laryngoscope, 129:2303-2308, 2019.
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Affiliation(s)
| | - Stephen J Ramey
- Sylvester Comprehensive Cancer Center, Miami, Florida, U.S.A.,Department of Radiation Oncology, Jackson Memorial Hospital, Miami, Florida, U.S.A
| | | | - Deukwoo Kwon
- Sylvester Comprehensive Cancer Center, Miami, Florida, U.S.A.,Department of Radiation Oncology, University of Miami, Miami, Florida, U.S.A
| | - Benjamin Farnia
- Sylvester Comprehensive Cancer Center, Miami, Florida, U.S.A.,Department of Radiation Oncology, Jackson Memorial Hospital, Miami, Florida, U.S.A
| | - Elizabeth Nicolli
- Sylvester Comprehensive Cancer Center, Miami, Florida, U.S.A.,Department of Otolaryngology, Miami, Florida, U.S.A
| | - Michael A Samuels
- Sylvester Comprehensive Cancer Center, Miami, Florida, U.S.A.,Department of Radiation Oncology, University of Miami, Miami, Florida, U.S.A
| | - Laura Freedman
- Sylvester Comprehensive Cancer Center, Miami, Florida, U.S.A.,Department of Radiation Oncology, University of Miami, Miami, Florida, U.S.A
| | - Nagy Elsayyad
- Sylvester Comprehensive Cancer Center, Miami, Florida, U.S.A.,Department of Radiation Oncology, University of Miami, Miami, Florida, U.S.A
| | - Raphael Yechieli
- Sylvester Comprehensive Cancer Center, Miami, Florida, U.S.A.,Department of Radiation Oncology, University of Miami, Miami, Florida, U.S.A
| | - Stuart E Samuels
- Sylvester Comprehensive Cancer Center, Miami, Florida, U.S.A.,Department of Radiation Oncology, University of Miami, Miami, Florida, U.S.A
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Burton BN, Labastide AS, Meineke MN, Schmidt UH, Gabriel RA. Cardiorespiratory morbidity and mortality of opioid overdose during admission to safety-net hospitals. J Clin Anesth 2018; 54:66-71. [PMID: 30408618 DOI: 10.1016/j.jclinane.2018.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/11/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVE Safety-net hospitals disproportionately care for high-risk patients. Prior work has shown safety-net hospitals to have inferior postoperative outcomes with higher cost and worse patient ratings. We aim to examine the association of hospital safety-net burden with morbidity and mortality in patients with opioid overdose hospital admission. DESIGN Retrospective cross-sectional analysis using the National Inpatient Sample registry from 2010 to 2014. SETTING Multi-institutional. PATIENTS We included 547, 399 patients admitted to a United States hospital with an International Classification of Disease, Ninth Revision, code of opioid overdose. To study the association of hospital safety-net burden on mortality and morbidity, we calculated hospital safety-net burden defined as the percent of Medicaid or uninsured among all admitted patients. Hospitals were categorized into one of three categories: low burden hospitals, medium burden hospitals, and high burden hospitals (i.e., safety-net hospitals). We performed a mixed effects multivariable logistic regression analysis to assess the association of hospital safety-net burden with short-term inpatient outcomes. INTERVENTION None. MEASUREMENTS The primary outcomes were inpatient mortality and morbidity. MAIN RESULTS Compared to MBHs and LBHs, HBHs had a greater proportion of minority patients (i.e., Black, Hispanic, and Native American) and patients with median household income in the lowest quartile (p < 0.001). Among prescription opioid overdose admissions, the odds of inpatient mortality and pulmonary and cardiac morbidity were also not significantly higher between HBHs versus LBHs (p > 0.05). CONCLUSIONS Safety-net hospital disproportionately care for vulnerable populations, however the odds of poor outcomes were no different in opioid overdose. Safety-net hospitals should have equal access to the funding and resources that allows them to deliver the same standard of care as their counterparts.
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Affiliation(s)
- Brittany N Burton
- School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Angele S Labastide
- School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Minhthy N Meineke
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA
| | - Ulrich H Schmidt
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA; Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, San Diego, CA, USA.
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Donoho DA, Patel A, Buchanan IA, Chow F, Ding L, Amar AP, Attenello F, Mack WJ. Treatment at Safety-Net Hospitals Is Associated with Delays in Coil Embolization in Patients with Subarachnoid Hemorrhage. World Neurosurg 2018; 120:e434-e439. [PMID: 30205228 DOI: 10.1016/j.wneu.2018.08.101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/11/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Successful endovascular management of aneurysmal subarachnoid hemorrhage (aSAH) requires timely access to substantial resources. Prior studies suggest an association between time to treatment and patient outcome. Patients treated at safety-net hospitals are thought to be particularly vulnerable to disparities in access to interventions that require substantial technologic resources. We hypothesized that patients with aSAH treated at safety-net hospitals are at greater risk for delayed access to endovascular treatment. METHODS Adults undergoing endovascular coiling procedures between 2002 and 2011 in the Nationwide Inpatient Sample were included. Hospitals in the quartile with the highest proportion of Medicaid or uninsured patients were defined as safety-net hospitals. A multivariate model including patient-level and hospital-level factors was constructed to permit analysis of delays in endovascular treatment (defined as time to treatment >3 days). RESULTS Analysis included 7109 discharges of patients with aSAH undergoing endovascular coil embolization procedures from 2002 to 2011. Median time to coil embolization in all patients was 1 day; 10.1% of patients waited >3 days until treatment. In multivariate analysis, patients treated at safety-net hospitals were more likely to have a prolonged time to coil embolization (odds ratio = 1.32, P < 0.01) compared with patients treated at low-burden hospitals. CONCLUSIONS After controlling for patient and hospital factors, individuals with aSAH treated at safety-net hospitals from 2002 to 2011 were more likely to have a delay to endovascular coil embolization than individuals treated at non-safety-net hospitals. This disparity could affect patient outcomes.
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Affiliation(s)
- Daniel A Donoho
- Department of Neurological Surgery, University of Southern California, Los Angeles, California
| | - Arati Patel
- Keck School of Medicine, University of Southern California, Los Angeles, California.
| | - Ian A Buchanan
- Department of Neurological Surgery, University of Southern California, Los Angeles, California
| | - Frances Chow
- Department of Neurology, University of Southern California, Los Angeles, California
| | - Li Ding
- Department of Preventive Medicine, University of Southern California, Los Angeles, California
| | - Arun P Amar
- Department of Neurological Surgery, University of Southern California, Los Angeles, California
| | - Frank Attenello
- Department of Neurological Surgery, University of Southern California, Los Angeles, California
| | - William J Mack
- Department of Neurological Surgery, University of Southern California, Los Angeles, California
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