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Calkins FM, Pagani NR, Bragg J, Gauthier Z, Salzler M. Neighborhood socioeconomic disadvantage does not predict need for manipulation under anesthesia or range of motion following total knee arthroplasty. J Orthop 2024; 58:146-149. [PMID: 39100542 PMCID: PMC11293519 DOI: 10.1016/j.jor.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 06/10/2024] [Accepted: 06/13/2024] [Indexed: 08/06/2024] Open
Abstract
Background Studies have linked socioeconomic factors including lower income and minority race with worse functional outcomes following total knee arthroplasty (TKA). Arthrofibrosis is a common complication following TKA, and manipulation under anesthesia (MUA) is an effective treatment option for arthrofibrosis. This study aimed to determine if neighborhood-level socioeconomic disadvantage predicts need for MUA and postoperative range of motion (ROM) among patients undergoing primary elective TKA. Methods We performed a retrospective cohort study of primary TKAs performed at a single institution over a three-year duration. Area Deprivation Index (ADI) was used to determine each patient's level of socioeconomic disadvantage based on their home address. Patients were allocated into three groups based on ADI: least socioeconomic disadvantage (ADI 1-3), middle socioeconomic disadvantage (ADI 4-6), and most socioeconomic disadvantage (ADI 7-10). Demographic factors and comorbid conditions were recorded. Bivariate analysis was used to evaluate the relationship between degree of socioeconomic disadvantage and need for MUA and postoperative ROM. Results In total, 600 patients were included and 26.7 % were categorized as most disadvantaged. In comparison to the middle and least disadvantaged groups, these patients were more likely to be Women (71.2 vs. 67.9 and 58.6 %; p = 0.027), younger (60.7 vs. 62.9 and 66.3 years; p < 0.001) and have higher BMI (34.9 vs. 33 and 31.7; p < 0.001) (most disadvantaged vs. middle and least). Analysis revealed no difference in rate of MUA (6.3 vs. 2.5 vs. 4 %; p = 0.179) or postoperative ROM (98 vs. 98 vs. 100°; p = 0.753) between the three groups (most, middle, and least disadvantaged, respectively). Conclusion Neighborhood socioeconomic disadvantage does not predict rate of MUA or postoperative ROM following TKA. Patients residing in neighborhoods with higher ADI who underwent TKA were more likely to be younger, Women, and have higher BMI, consistent with previous literature. Our results support efforts to improve access to orthopaedic care, including TKA, to patients of all socioeconomic levels.
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Affiliation(s)
| | - Nicholas R. Pagani
- Department of Orthopaedics, New England Baptist Hospital, Boston, MA, USA
| | - Jack Bragg
- Department of Orthopaedics, Tufts Medical Center, Boston, MA, USA
| | | | - Matthew Salzler
- Department of Orthopaedics, Tufts Medical Center, Boston, MA, USA
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Rachoin JS, Hunter K, Varallo J, Cerceo E. Impact of time from discharge to readmission on outcomes: an observational study from the US National Readmission Database. BMJ Open 2024; 14:e085466. [PMID: 39209489 PMCID: PMC11367292 DOI: 10.1136/bmjopen-2024-085466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 08/13/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND The Hospital Readmission Reduction Programme (HRRP) was created to decrease the number of hospital readmissions for acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure (HF), pneumonia (PNA), coronary artery bypass graft (CABG), elective total hip arthroplasty (THA) and total knee arthroplasty. OBJECTIVES To analyse the impact of the HRRP on readmission rates from 2010 to 2019 and how time to readmission impacted outcomes. DESIGN Population-based retrospective study. SETTING All patients included in the US National Readmission database from 2010 to 2019. PATIENTS We recorded demographic and clinical variables. MEASUREMENTS Using linear regression models, we analysed the association between readmission status and timing with death and length of stay (LOS) outcomes. We transformed LOS and charges into log-LOS and log-charges to normalise the data. RESULTS There were 31 553 363 records included in the study. Of those, 4 593 228 (14.55%) were readmitted within 30 days. From 2010 to 2019, readmission rates for COPD (20.8%-19.8%), HF (24.9%-21.9%), PNA (16.4%-15.1%), AMI (15.6%-12.9%) and TKR (4.1%-3.4%) decreased whereas CABG (10.2%-10.6%) and THA (4.2%-5.8%) increased. Readmitted patients were at higher risk of mortality (6% vs 2.8%) and had higher LOS (3 (2-5) vs 4 (3-7)). Patients readmitted within 10 days had a mortality 6.4% higher than those readmitted in 11-20 days (5.4%) and 21-30 days (4.6%). Increased time from discharge to readmission was associated with a lower likelihood of mortality, like LOS. CONCLUSION Over the last 10 years, readmission rates decreased for most conditions included in the HRRP except CABG and THA. Patients readmitted shortly after discharge were at higher risk of death.
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Affiliation(s)
| | - Krystal Hunter
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
- Cooper Research Institute, Cooper University Health Care, Camden, New Jersey, USA
| | - Jennifer Varallo
- Cooper Research Institute, Cooper University Health Care, Camden, New Jersey, USA
| | - Elizabeth Cerceo
- Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA
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Lui B, Khusid E, Tangel VE, Jiang SY, Abramovitz SE, Oxford CM, White RS. Disparities in postpartum readmission by patient- and hospital-level social risk factors in the United States: a retrospective multistate analysis, 2015-2020. Int J Obstet Anesth 2024; 59:103998. [PMID: 38719764 DOI: 10.1016/j.ijoa.2024.103998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 04/05/2024] [Accepted: 04/10/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Postpartum readmission is an area of focus for improving obstetric care and reducing costs. We examined disparities in all-cause 30-day postpartum readmission by patient- and hospital-level factors in the United States. METHODS We conducted a retrospective cohort study using 2015-2020 records from the State Inpatient Databases from four states. Generalized linear mixed models were constructed to estimate the effects of individual patient- and hospital-level factors on adjusted odds of 30-day readmission after controlling for confounders. Stratified analyses by delivery and anesthesia type (New York only) and interaction models were performed. RESULTS Black mothers were more likely than White mothers to be readmitted within 30-days postpartum (aOR 1.57, 95% CI 1.52 to 1.61). Mothers with public insurance had increased odds of readmission compared with those with private insurance (Medicare: aOR 2.13, 95% CI 1.95 to 2.32; Medicaid: aOR 1.14, 95% CI 1.11 to 1.17). Compared with mothers in the lowest income quartile, those in the highest quartile experienced a 14% lower odds of readmission (aOR 0.86, 95% CI 0.83 to 0.89). There were no significant associations between hospital-level characteristics and readmission. Black mothers were more likely to be readmitted regardless of delivery type and most combinations of delivery and anesthesia type. Black mothers from the highest income quartile were more likely to be readmitted than White mothers from the lowest income quartile. CONCLUSION Substantial disparities in 30-day postpartum readmissions by patient-level social factors were observed, particularly amongst Black mothers. Action is needed to address and mitigate disparities in postpartum readmission.
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Affiliation(s)
- B Lui
- Weill Cornell Medical College, Weill Cornell Medicine, New York, NY, USA
| | - E Khusid
- Weill Cornell Medical College, Weill Cornell Medicine, New York, NY, USA
| | - V E Tangel
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - S Y Jiang
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - S E Abramovitz
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - C M Oxford
- Department of Maternal and Fetal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - R S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.
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Kim H, Hart KD, Senders A, Schabel K, Ibrahim SA. Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups. Popul Health Manag 2024; 27:128-136. [PMID: 38442304 DOI: 10.1089/pop.2023.0310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
Hip and knee replacement have been marked by racial and ethnic disparities in both utilization and postoperative adverse events among Medicare beneficiaries, but limited knowledge exists regarding racial and ethnic differences in joint replacement care among Medicaid beneficiaries. To close this gap, this study used Medicaid claims in 2018 and described racial and ethnic differences in the utilization and postoperative adverse events of elective joint replacements among Medicaid beneficiaries. Among the 2,260,272 Medicaid beneficiaries, 5987 had an elective joint replacement in 2018. Asian (0.05%, 95% confidence interval [CI]: 0.03%-0.07%) and Hispanic beneficiaries (0.12%, 95% CI: 0.07%-0.18%) received joint replacements less frequently than American Indian and Alaska Native (0.41%, 95% CI: 0.27%-0.55%), Black (0.33%, 95% CI: 0.19%-0.48%), and White (0.37%, 95% CI: 0.25%-0.50%) beneficiaries. Black patients demonstrated the highest probability of 90-day emergency department visits (34.8%, 95% CI: 32.7%-37.0%) among all racial and ethnic groups and a higher probability of 90-day readmission (8.0%, 95% CI: 6.9%-9.0%) than Asian (3.4%, 95% CI: 0.7%-6.0%) and Hispanic patients (4.4%, 95% CI: 3.4%-5.3%). These findings indicate evident disparities in postoperative adverse events across racial and ethnic groups, with Black patients demonstrating the highest probability of 90-day emergency department visits. This study represents an initial exploration of the racial and ethnic differences in joint replacement care among Medicaid beneficiaries and lay the groundwork for further investigation into contributing factors of the observed disparities.
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Affiliation(s)
- Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Kyle D Hart
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Angela Senders
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Kathryn Schabel
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon, USA
| | - Said A Ibrahim
- Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, USA
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Pearson ZC, Ahiarakwe U, Bahoravitch TJ, Schmerler J, Harris AB, Thakkar SC, Best MJ, Srikumaran U. Social Determinants of Health Disparities Increase the Rate of Complications After Total Knee Arthroplasty. J Arthroplasty 2023; 38:2531-2536.e3. [PMID: 37659681 DOI: 10.1016/j.arth.2023.08.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/22/2023] [Accepted: 08/27/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND Few studies have investigated whether social determinants of health disparities (SDHD), which include economic, social, education, health care, and environmental factors, identified through International Classification of Diseases (ICD) codes are associated with increased odds for poor health outcomes. We aimed to investigate the association between SDHD, identified through this novel methodology, as well as postoperative complications following total knee arthroplasty (TKA). METHODS Using a national insurance claims database, a retrospective cohort analysis was performed. Patients were selected using Current Procedural Terminology and ICD codes for primary TKA between 2010 and 2019. Patients were stratified into 2 groups using ICD codes, those who had SDHD and those who did not, and propensity matched 1:1 for age, sex, a comorbidity score, and other comorbidities. After matching, 207,844 patients were included, with 103,922 patients in each cohort. Odds ratios (ORs) for 90-day medical and 2-year surgical complications were obtained using multivariable logistical regressions. RESULTS In patients who have SDHD, multivariable analysis demonstrated higher odds of readmission (OR): 1.12; P = .013) and major and minor medical complications (OR: 2.09; P < .001) within 90-days as well as higher odds of revision surgery (OR: 1.77; P < .001) and periprosthetic joint infection (OR: 1.30; P < .001) within 2-years. CONCLUSION The SDHD are an independent risk factor for revision surgery and periprosthetic joint infection after TKA. In addition, SDHD is also an independent risk factor for all-cause hospital readmissions and both minor and major complications. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Zachary C Pearson
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Uzoma Ahiarakwe
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Tyler J Bahoravitch
- The School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia
| | - Jessica Schmerler
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Savyasachi C Thakkar
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Mathew J Best
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
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Baidya J, Gordon AM, Nian PP, Schwartz J, Golub IJ, Abdelgawad AA, Kang KK. Social determinants of health in patients undergoing hemiarthroplasty: are they associated with medical complications, healthcare utilization, and payments for care? Arch Orthop Trauma Surg 2023; 143:7073-7080. [PMID: 37697051 DOI: 10.1007/s00402-023-05045-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/20/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION Social determinants of health (SDOH) have previously been shown to impact orthopedic surgery outcomes. This study assessed whether greater socioeconomic disadvantage in patients undergoing hemiarthroplasty following femoral neck fracture was associated with differences in (1) medical complications, (2) emergency department (ED) utilization, (3) readmission rates, and (4) payments for care. METHODS A US nationwide database was queried for hemiarthroplasties performed between 2010 and 2020. Area Deprivation Index (ADI), a validated measure of socioeconomic disadvantage reported on a scale of 0-100, was used to compare two cohorts of greater and lesser deprivation. Patients undergoing hemiarthroplasty from high ADI (95% +) were 1:1 propensity score matched to a comparison group of lower ADI (0-94%) while controlling for age, sex, and Elixhauser Comorbidity Index. This yielded 75,650 patients evenly distributed between the two cohorts. Outcomes studied were 90-day medical complications, ED utilizations, readmissions, and payments for care. Multivariate logistic regression models were utilized to calculate odds ratios (ORs) of the relationship between ADI and outcomes. p Values < 0.05 were significant. RESULTS Patients of high ADI developed greater medical complications (46.74% vs. 44.97%; OR 1.05, p = 0.002), including surgical site infections (1.19% vs. 1.00%; OR 1.20, p = 0.011), cerebrovascular accidents (1.64% vs. 1.41%; OR 1.16, p = 0.012), and respiratory failures (2.27% vs. 2.02%; OR 1.13, p = 0.017) compared to patients from lower ADIs. Although comparable rates of ED visits (2.92% vs. 2.86%; OR 1.02, p = 0.579), patients from higher ADI were readmitted at diminished rates (10.57% vs. 11.06%; OR 0.95, p = 0.027). Payments were significantly higher on the day of surgery ($7,570 vs. $5,974, p < 0.0001), as well as within 90 days after surgery ($12,700 vs. $10,462, p < 0.0001). CONCLUSIONS Socioeconomically disadvantaged patients experience increased 90-day medical complications and payments, similar ED utilizations, and decreased readmissions. These findings can be used to inform healthcare providers to minimize disparities in care. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Joydeep Baidya
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA
- College of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Adam M Gordon
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA.
- Questrom School of Business, Boston University, Boston, MA, USA.
| | - Patrick P Nian
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA
- College of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Jake Schwartz
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA
| | - Ivan J Golub
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA
| | - Amr A Abdelgawad
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA
| | - Kevin K Kang
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA
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Rajahraman V, Lawrence KW, Berzolla E, Lajam CM, Schwarzkopf R, Rozell JC. The Benefit in Patient-Reported Outcomes After Total Knee Arthroplasty was Comparable Across Income Quartiles. J Arthroplasty 2023; 38:1652-1657. [PMID: 36963532 DOI: 10.1016/j.arth.2023.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND Few studies have assessed how socioeconomic status (SES) influences patient-reported outcomes (PROMs) after total knee arthroplasty (TKA). This study evaluated the impact of patient median ZIP code income levels on PROMs after TKA. METHODS We retrospectively reviewed patients at our institution undergoing primary, unilateral TKA from 2017 to 2020. Patients who did not have one-year postoperative PROMs were excluded. Patients were stratified based on the quartile of their home ZIP code median income from United States Census Bureau data. There were 1,267 patients included: 98 in quartile 1 (median income ≤ $46,308) (7.7%); 126 in quartile 2 (median income $46,309-$57,848) (10.0%); 194 in quartile 3 (median income $57,849-$74,011) (15.7%); and 849 in quartile 4 (median income ≥ $74,012) (66.4%). We collected baseline demographic data, 2-year outcomes, and PROMs preoperatively, as well as at 12 weeks and one year, postoperatively. RESULTS The Knee Injury and Osteoarthritis Outcome Score for Joint Replacement was significantly higher in quartile 4 preoperatively (P < .001), 12 weeks postoperatively (P < .001), and one year postoperatively (P < .001). There were no significant differences in delta improvements of Knee Injury and Osteoarthritis Outcome Score for Joint Replacement from preoperative to 12 weeks or one year postoperatively. There were no significant differences in lengths of stay, discharge dispositions, readmissions, or revisions. CONCLUSION Patients from lower income areas have slightly worse knee function preoperatively and worse outcomes following TKA. However, improvements in PROMs throughout the first year postoperatively are similar across income quartiles, suggesting that patients from lower income quartiles achieve comparable therapeutic benefits from TKA. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
- Vinaya Rajahraman
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Kyle W Lawrence
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Emily Berzolla
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Claudette M Lajam
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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Upfill-Brown A, Paisner N, Sassoon A. Racial disparities in post-operative complications and discharge destination following total joints arthroplasty: a national database study. Arch Orthop Trauma Surg 2023; 143:2227-2233. [PMID: 35695924 PMCID: PMC10030399 DOI: 10.1007/s00402-022-04485-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 05/16/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The objective of this study was to explore race-based differences in 30-day complication rates following total joint arthroplasty (TJA) using a large national database. METHODS Patients undergoing primary, elective THA and TKA between 2012 and 2018 were retrospectively reviewed using the ACS-NSQIP. We compared Black and Hispanic patients with non-Hispanic White patients using multivariate statistical models adjusting for demographic, operative, and medical characteristics. RESULTS A total of 324,795 and 200,023 patients undergoing THA and TKA, respectively, were identified. After THA, compared to White patients, Black and Hispanic patients were more likely to be diagnosed with VTE (p < 0.001), receive a blood transfusion (p < 0.001), and to be discharged to an inpatient facility (p < 0.001). After TKA, compared to White patients, Black and Hispanic patients were more likely to experience a major complication (p < 0.001 and p = 0.008, respectively), be diagnosed with VTE (p < 0.001), and be discharged to a facility (p < 0.001). CONCLUSIONS Our findings indicate higher rates of VTE, blood transfusions, and discharge to an inpatient facility for Black and Hispanic patients when compared to White patients following TJA, though we are unable to comment on the etiology of these disparities. These results may contribute to a growing divide with respect to outcomes and access to TJA for these at-risk patient populations.
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Affiliation(s)
- Alex Upfill-Brown
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1225 15thSt, Suite 3145, Santa Monica, CA, 90404, USA
| | - Noah Paisner
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1225 15thSt, Suite 3145, Santa Monica, CA, 90404, USA
- Pacific Northwest University School of Health Sciences, Yakima, WA, USA
| | - Adam Sassoon
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1225 15thSt, Suite 3145, Santa Monica, CA, 90404, USA.
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Adelani MA, Marx CM, Humble S. Are Neighborhood Characteristics Associated With Outcomes After THA and TKA? Findings From a Large Healthcare System Database. Clin Orthop Relat Res 2023; 481:226-235. [PMID: 35503679 PMCID: PMC9831171 DOI: 10.1097/corr.0000000000002222] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 04/05/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Non-White patients have higher rates of discharge to an extended care facility, hospital readmission, and emergency department use after primary THA and TKA. The reasons for this are unknown. Place of residence, which can vary by race, has been linked to poorer healthcare outcomes for people with many health conditions. However, the potential relationship between place of residence and disparities in these joint arthroplasty outcomes is unclear. QUESTIONS/PURPOSES (1) Are neighborhood-level characteristics, including racial composition, marital proportions, residential vacancy, educational attainment, employment proportions, overall deprivation, access to medical care, and rurality associated with an increased risk of discharge to a facility, readmission, and emergency department use after elective THA and TKA? (2) Are the associations between neighborhood-level characteristics and discharge to a facility, readmission, and emergency department use the same among White and Black patients undergoing elective THA and TKA? METHODS Between 2007 and 2018, 34,008 records of elective primary THA or TKA for osteoarthritis, rheumatoid arthritis, or avascular necrosis in a regional healthcare system were identified. After exclusions for unicompartmental arthroplasty, bilateral surgery, concomitant procedures, inability to geocode a residential address, duplicate records, and deaths, 21,689 patients remained. Ninety-seven percent of patients in this cohort self-identified as either White or Black, so the remaining 659 patients were excluded due to small sample size. This left 21,030 total patients for analysis. Discharge destination, readmissions within 90 days of surgery, and emergency department visits within 90 days were identified. Each patient's street address was linked to neighborhood characteristics from the American Community Survey and Area Deprivation Index. A multilevel, multivariable logistic regression analysis was used to model each outcome of interest, controlling for clinical and individual sociodemographic factors and allowing for clustering at the neighborhood level. The models were then duplicated with the addition of neighborhood characteristics to determine the association between neighborhood-level factors and each outcome. The linear predictors from each of these models were used to determine the predicted risk of each outcome, with and without neighborhood characteristics, and divided into tenths. The change in predicted risk tenths based on the model containing neighborhood characteristics was compared to that without neighborhood characteristics.The change in predicted risk tenth for each outcome was stratified by race. RESULTS After controlling for age, sex, insurance type, surgery type, and comorbidities, we found that an increase of one SD of neighborhood unemployment (odds ratio 1.26 [95% confidence interval 1.17 to 1.36]; p < 0.001) was associated with an increased likelihood of discharge to a facility, whereas an increase of one SD in proportions of residents receiving public assistance (OR 0.92 [95% CI 0.86 to 0.98]; p = 0.008), living below the poverty level (OR 0.82 [95% CI 0.74 to 0.91]; p < 0.001), and being married (OR 0.80 [95% CI 0.71 to 0.89]; p < 0.001) was associated with a decreased likelihood of discharge to a facility. Residence in areas one SD above mean neighborhood unemployment (OR 1.12 [95% CI [1.04 to 1.21]; p = 0.002) was associated with increased rates of readmission. An increase of one SD in residents receiving food stamps (OR 0.83 [95% CI 0.75 to 093]; p = 0.001), being married (OR 0.89 [95% CI 0.80 to 0.99]; p = 0.03), and being older than 65 years (OR 0.93 [95% CI 0.88 to 0.98]; p = 0.01) was associated with a decreased likelihood of readmission. A one SD increase in the percentage of Black residents (OR 1.11 [95% CI 1.00 to 1.22]; p = 0.04) and unemployed residents (OR 1.15 [95% CI 1.05 to 1.26]; p = 0.003) was associated with a higher likelihood of emergency department use. Living in a medically underserved area (OR 0.82 [95% CI 0.68 to 0.97]; p = 0.02), a neighborhood one SD above the mean of individuals using food stamps (OR 0.81 [95% CI 0.70 to 0.93]; p = 0.004), and a neighborhood with an increasing percentage of individuals older than 65 years (OR 0.90 [95% CI 0.83 to 0.96]; p = 0.002) were associated with a lower likelihood of emergency department use. With the addition of neighborhood characteristics, the risk prediction tenths of the overall cohort remained the same in more than 50% of patients for all three outcomes of interest. When stratified by race, neighborhood characteristics increased the predicted risk for 55% of Black patients for readmission compared with 17% of White patients (p < 0.001). The predicted risk tenth increased for 60% of Black patients for emergency department use compared with 21% for White patients (p < 0.001). CONCLUSION These results can be used to identify high-risk patients who might benefit from preemptive interventions to avoid these particular outcomes and to create more realistic, comprehensive risk adjustment models for value-based care programs. Additionally, this study demonstrates that neighborhood characteristics are associated with greater risk for these outcomes among Black patients compared with White patients. Further studies should consider that race/ethnicity and neighborhood characteristics may not function independently from each other. Understanding this link between race and place of residence is essential for future racial disparities research. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
| | - Christine M. Marx
- Washington University School of Medicine, Department of Surgery, Division of Public Health Sciences, St. Louis, MO, USA
| | - Sarah Humble
- Washington University School of Medicine, Department of Surgery, Division of Public Health Sciences, St. Louis, MO, USA
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Dlott CC, O'Connor MI, Wiznia DH. The Use of Race in Risk Assessment Tools Contributes to Systemic Racism. J Racial Ethn Health Disparities 2023; 10:1-3. [PMID: 36414930 DOI: 10.1007/s40615-022-01451-y] [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: 05/23/2022] [Revised: 10/17/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022]
Abstract
Many patients suffer from hip or knee osteoarthritis and elect to pursue total joint arthroplasty (TJA). Though perioperative risk is an inherent component of surgery, calculators that assess the risk of complications following TJA can help both surgeons and patients make informed decisions about the risk of surgery and aid in shared decision-making discussions. The inclusion of race in a risk calculator for readmission after TJA is flawed and unacceptable because a patient's race does not increase their risk of a complication after total joint replacement.
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Affiliation(s)
- Chloe C Dlott
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA.
| | - Mary I O'Connor
- Movement Is Life, Washington, DC, USA.,Vori Health, Nashville, TN, USA
| | - Daniel H Wiznia
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA.,Movement Is Life, Washington, DC, USA
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Sarpong NO. CORR Insights®: Are Neighborhood Characteristics Associated With Outcomes After THA and TKA? Findings From a Large Healthcare System Database. Clin Orthop Relat Res 2023; 481:236-238. [PMID: 36322911 PMCID: PMC9831151 DOI: 10.1097/corr.0000000000002476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 10/07/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Nana O Sarpong
- Assistant Professor of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Rudisill SS, Varady NH, Birir A, Goodman SM, Parks ML, Amen TB. Racial and Ethnic Disparities in Total Joint Arthroplasty Care: A Contemporary Systematic Review and Meta-Analysis. J Arthroplasty 2023; 38:171-187.e18. [PMID: 35985539 DOI: 10.1016/j.arth.2022.08.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total joint arthroplasty (TJA) is one of the most common surgical procedures in the United States; however, racial and ethnic disparities in utilizations and outcomes have been well documented. This systematic review and meta-analysis investigated associations between race/ethnicity and several metrics in total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS In August 2021, PubMed, Scopus, CINAHL, and SPORTDiscus databases were queried. Sixty three studies investigating racial/ethnic disparities in TJA utilizations, complications, mortalities, lengths of stay (LOS), discharge dispositions, readmissions, and reoperations were included. Study quality was assessed using a modified Newcastle-Ottawa Scale. RESULTS A majority of studies demonstrated disparities in TJA utilizations and outcomes. Black patients exhibited higher rates of 30-day complications (THA odds ratio [OR] 1.18, 95% confidence interval [CI] 1.08-1.29; TKA OR 1.20, 95% CI 1.10-1.31), 30-day mortality (THA OR 1.27, 95% CI 1.08-1.48), prolonged LOS (THA mean difference [MD] +0.27 days, 95% CI 0.21-0.33; TKA MD +0.30 days, 95% CI 0.20-0.40), nonhome discharges (THA OR 1.47, 95% CI 1.37-1.57; TKA OR 1.65, 95% CI 1.38-1.96), and 30-day readmissions (THA OR 1.13, 95% CI 1.08-1.19; TKA OR 1.19, 95% CI 1.16-1.21) than White patients. Rates of complications (THA 1.18, 95% CI 1.03-1.36), prolonged LOS (TKA MD +0.20 days, 95% CI 0.17-0.23), and nonhome discharges (THA OR 1.26, 95% CI 1.10-1.45; TKA OR 1.37, 95% CI 1.22-1.53) were also increased among Hispanic patients, while Asian patients experienced longer LOS (TKA MD +0.09 days, 95% CI 0.05-0.12) but fewer readmissions. Outcomes among American Indian-Alaska Native and Pacific Islander patients were infrequently reported but similarly inequitable. CONCLUSION Racial and ethnic disparities in TJA utilizations and outcomes are apparent, with minority patients often demonstrating lower rates of utilizations and worse postoperative outcomes than White patients. Continued research is needed to evaluate the efficacy of recent efforts dedicated to eliminating inequalities in TJA care. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Samuel S Rudisill
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York; Rush Medical College of Rush University, Chicago, Illinois
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Aseal Birir
- Harvard Medical School, Boston, Massachusetts
| | - Susan M Goodman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Michael L Parks
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
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Alvarez PM, McKeon JF, Spitzer AI, Krueger CA, Pigott M, Li M, Vajapey SP. Socioeconomic factors affecting outcomes in total knee and hip arthroplasty: a systematic review on healthcare disparities. ARTHROPLASTY (LONDON, ENGLAND) 2022; 4:36. [PMID: 36184658 PMCID: PMC9528115 DOI: 10.1186/s42836-022-00137-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/13/2022] [Indexed: 11/07/2022]
Abstract
Background Recent studies showed that healthcare disparities exist in use of and outcomes after total joint arthroplasty (TJA). This systematic review was designed to evaluate the currently available evidence regarding the effect socioeconomic factors, like income, insurance type, hospital volume, and geographic location, have on utilization of and outcomes after lower extremity arthroplasty. Methods A comprehensive search of the literature was performed by querying the MEDLINE database using keywords such as, but not limited to, “disparities”, “arthroplasty”, “income”, “insurance”, “outcomes”, and “hospital volume” in all possible combinations. Any study written in English and consisting of level of evidence I-IV published over the last 20 years was considered for inclusion. Quantitative and qualitative analyses were performed on the data. Results A total of 44 studies that met inclusion and quality criteria were included for analysis. Hospital volume is inversely correlated with complication rate after TJA. Insurance type may not be a surrogate for socioeconomic status and, instead, represent an independent prognosticator for outcomes after TJA. Patients in the lower-income brackets may have poorer access to TJA and higher readmission risk but have equivalent outcomes after TJA compared to patients in higher income brackets. Rural patients have higher utilization of TJA compared to urban patients. Conclusion This systematic review shows that insurance type, socioeconomic status, hospital volume, and geographic location can have significant impact on patients’ access to, utilization of, and outcomes after TJA. Level of evidence IV. Supplementary Information The online version contains supplementary material available at 10.1186/s42836-022-00137-4.
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Affiliation(s)
- Paul M. Alvarez
- grid.412332.50000 0001 1545 0811Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
| | - John F. McKeon
- grid.412332.50000 0001 1545 0811Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Andrew I. Spitzer
- grid.50956.3f0000 0001 2152 9905Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, USA
| | - Chad A. Krueger
- grid.512234.30000 0004 7638 387XDepartment of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Matthew Pigott
- grid.412332.50000 0001 1545 0811Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Mengnai Li
- grid.412332.50000 0001 1545 0811Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Sravya P. Vajapey
- grid.412332.50000 0001 1545 0811Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
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Evaluating Resource Utilization for In-Person and Virtual Joint Classes in Total Joint Arthroplasty: An Analysis of Attendance Patterns at a Large Metropolitan Health System. J Arthroplasty 2022; 37:1708-1714. [PMID: 35378234 DOI: 10.1016/j.arth.2022.03.079] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/20/2022] [Accepted: 03/28/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Provider-run "joint classes" educate total joint arthroplasty (TJA) patients on how to best prepare for surgery and maximize recovery. There is no research on potential healthcare inequities in the context of joint classes or on the impact of the recent shift toward telehealth due to coronavirus disease 2019 (COVID-19). Using data from a large metropolitan health system, we aimed to (1) identify demographic patterns in prepandemic joint class attendance and (2) understand the impact of telehealth on attendance. METHODS We included data on 3,090 TJA patients from three centers, each with a separately operated joint class. Attendance patterns were assessed prepandemic and after the resumption of elective surgeries when classes transitioned to telehealth. Statistical testing included standardized differences (SD > 0.1 indicates significance) and a multivariate linear regression. RESULTS The in-person and telehealth attendance rates were 69.9% and 69.2%, respectively. Joint class attendance was significantly higher for non-White, Hispanic, non-English primary language, Medicaid, and Medicare patients (all SD > 0.1). Age was a determinant of attendance for telehealth (SD > 0.1) but not for in-person (SD = 0.04). Contrastingly, physical distance from hospital was significant for in-person (SD > 0.1) but not for telehealth (SD = 0.06). On a multivariate analysis, distance from hospital (P < .05) and telehealth (P < .0001) were predictors of failed class attendance. CONCLUSION This work highlights the relative importance of joint classes in specific subgroups of patients. Although telehealth attendance was lower, telehealth alleviated barriers to access related to physical distance but increased barriers for older patients. These results can guide providers on preoperative education and the implementation of telehealth.
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O'Shaughnessy S, Tangel V, Dzotsi S, Jiang S, White R, Hoyler M. Non-White Race/Ethnicity and Female Sex Are Associated with Increased Allogeneic Red Blood Cell Transfusion in Cardiac Surgery Patients: 2007-2018. J Cardiothorac Vasc Anesth 2022; 36:1908-1918. [PMID: 34969561 DOI: 10.1053/j.jvca.2021.11.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate racial and/or ethnic and sex disparities in allogeneic and autologous red blood cell (RBC) transfusions in cardiac surgery. DESIGN A retrospective observational study. SETTING 2007 to 2018 data from FL, MD, KY, WA, NY, and CA from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. PARTICIPANTS A total of 710,296 inpatients who underwent elective or emergency coronary artery bypass grafting (CABG), cardiac valve surgery,or combination CABG and/or valve surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were cohorted by race and/or ethnicity and sex, as defined by SID-HCUP. Demographic characteristics and comorbidities were compared. Rates and risk-adjusted odds ratios (aOR) were calculated for allogeneic and autologous RBC transfusion (primary outcomes). Additional secondary analyses were conducted for in-hospital mortality, 30-day readmission, 90-day readmission, hospital length of stay, and total charges to examine the effect of RBC transfusion status. Effect modification between race and sex was assessed. When controlling for patient demographics, comorbidities, and hospital characteristics, non-White patients were more likely to receive an allogeneic RBC transfusion during cardiac surgery than White patients (Black: aOR 1.17, 99% CI 1.13-1.20, p < 0.001, Hispanic: aOR 1.22, 99% CI 1.19-1.22, p < 0.001). Women were more likely to receive allogeneic RBC than men (aOR 1.69, 99% CI 1.66-1.72, p < 0.001). In interaction models, non-White women had the highest odds of allogeneic blood transfusion as compared to White men (reference category; Black women: aOR 2.04, 99% CI 1.91-2.17, p < 0.001, Hispanic women: aOR 2.03, 99% CI 1.90-2.16, p < 0.001). CONCLUSION These findings highlighted the differences in the rates of allogeneic RBC transfusion for non-White and female patients undergoing cardiac surgery, which is a well-established marker of poorer outcomes.
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Affiliation(s)
- Sinead O'Shaughnessy
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY.
| | - Virginia Tangel
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Safiya Dzotsi
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Silis Jiang
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Robert White
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Marguerite Hoyler
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
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Dlott CC, Wiznia DH. CORR Synthesis: How Might the Preoperative Management of Risk Factors Influence Healthcare Disparities in Total Joint Arthroplasty? Clin Orthop Relat Res 2022; 480:872-890. [PMID: 35302972 PMCID: PMC9029894 DOI: 10.1097/corr.0000000000002177] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 02/24/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Chloe C. Dlott
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Daniel H. Wiznia
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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Potentially preventable hospital readmissions after patients' first stroke in Taiwan. Sci Rep 2022; 12:3743. [PMID: 35260680 PMCID: PMC8904540 DOI: 10.1038/s41598-022-07791-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/22/2022] [Indexed: 11/08/2022] Open
Abstract
Readmission is an important indicator of the quality of care. The purpose of this study was to explore the probabilities and predictors of 30-day and 1-year potentially preventable hospital readmission (PPR) after a patient's first stroke. We used claims data from the National Health Insurance (NHI) from 2010 to 2018. Multinomial logistic regression was used to assess the predictors of 30-day and 1-year PPR. A total of 41,921 discharged stroke patients was identified. We found that hospital readmission rates were 15.48% within 30-days and 47.25% within 1-year. The PPR and non-PPR were 9.84% (4123) and 5.65% (2367) within 30-days, and 30.65% (12,849) and 16.60% (6959) within 1-year, respectively. The factors of older patients, type of stroke, shorter length of stay, higher Charlson Comorbidity Index (CCI), higher stroke severity index (SSI), regional hospital, public and private hospital, and hospital in the lower urbanized area were associated significantly with the 30-day PPR. In addition, the factors of male, hospitalization year, and monthly income were associated significantly with 1-year PPR. The ORs of long-term PPR showed a decreasing trend since implementing the national health insurance post-acute care (PAC) program in 2014 and a dramatic drop in 2018 after the government expanded the long-term care plan-LTC 2.0 in 2017. The results showed that better discharge planning, implementing post-acute care programs and long-term care plan-LTC 2.0 may benefit the care of stroke patients and help reduce long-term readmission in Taiwan.
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Alvarez PM, McKeon JF, Spitzer AI, Krueger CA, Pigott M, Li M, Vajapey SP. Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities. JBJS Rev 2022; 10:01874474-202203000-00003. [PMID: 35231001 DOI: 10.2106/jbjs.rvw.21.00161] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Previous studies have shown that utilization and outcomes of total joint arthroplasty (TJA) are not equivalent across different patient cohorts. This systematic review was designed to evaluate the currently available evidence regarding the effect that patient race has, if any, on utilization and outcomes of lower-extremity arthroplasty in the United States. METHODS A literature search of the MEDLINE database was performed using keywords such as "disparities," "arthroplasty," "race," "joint replacement," "hip," "knee," "inequities," "inequalities," "health," and "outcomes" in all possible combinations. All English-language studies with a level of evidence of I through IV published over the last 20 years were considered for inclusion. Quantitative and qualitative analyses were performed on the collected data. RESULTS A total of 82 articles were included. There was a significantly lower utilization rate of lower-extremity TJA among Black, Hispanic, and Asian patients compared with White patients (p < 0.05). Black and Hispanic patients had lower expectations regarding postoperative outcomes and their ability to participate in various activities after surgery, and they were less likely than White patients to be familiar with the arthroplasty procedure prior to presentation to the orthopaedic surgeon (p < 0.05). Black patients had increased risks of major complications, readmissions, revisions, and discharge to institutional care after TJA compared with White patients (p < 0.05). Hispanic patients had increased risks of complications (p < 0.05) and readmissions (p < 0.0001) after TJA compared with White patients. Black and Hispanic patients reached arthroplasty with poorer preoperative functional status, and all minority patients were more likely to undergo TJA at low-quality, low-volume hospitals compared with White patients (p < 0.05). CONCLUSIONS This systematic review shows that lower-extremity arthroplasty utilization differs by racial/ethnic group, and that some of these differences may be partly explained by patient expectations, preferences, and cultural differences. This study also shows that outcomes after lower-extremity arthroplasty differ vastly by racial/ethnic group, and that some of these differences may be driven by differences in preoperative functional status and unequal access to care. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Paul M Alvarez
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John F McKeon
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Andrew I Spitzer
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Chad A Krueger
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | - Matthew Pigott
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mengnai Li
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sravya P Vajapey
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Chun DS, Leonard AK, Enchill Z, Suleiman LI. Racial Disparities in Total Joint Arthroplasty. Curr Rev Musculoskelet Med 2021; 14:434-440. [PMID: 34626322 PMCID: PMC8733080 DOI: 10.1007/s12178-021-09718-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW The primary aim of this review was to evaluate recently published total joint arthroplasty (TJA) studies in order to accurately summarize the current concepts regarding racial and ethnic disparities in total joint arthroplasty. RECENT FINDINGS Many studies found that racial and ethnic disparities in TJA are present in all phases of arthroplasty care including access to, utilization of, and postoperative outcomes after TJA. Factors that limit patient access to TJA-increased patient comorbidities, lower socioeconomic status, and Medicaid/uninsured status-are also disproportionately associated with underrepresented patient populations. Minority patients are more likely to require more intensive postoperative rehabilitation and non-home discharge placement. This in turn potentially adds additional concerns regarding hospital/provider reimbursement in light of the current Medicare/Medicaid model for arthroplasty surgeons, thus creating a recurrent cycle in which disparities in TJA reflect the complex interplay of overall health disparities and access inequalities associated with racial and ethnic biases. Literature demonstrating evidenced-based interventions to minimize these disparities is sparse, but the multifactorial cause of disparities in TJA highlights the need for multifaceted solutions on both a systemic and individual level.
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Affiliation(s)
- Danielle S Chun
- Department of Orthopaedic Surgery, Northwestern University, 259 E. Erie St. 13th Floor, Chicago, IL, 60611, USA
| | - Annemarie K Leonard
- Department of Orthopaedic Surgery, Northwestern University, 259 E. Erie St. 13th Floor, Chicago, IL, 60611, USA
| | - Zenaida Enchill
- Department of Orthopaedic Surgery, Northwestern University, 259 E. Erie St. 13th Floor, Chicago, IL, 60611, USA
| | - Linda I Suleiman
- Department of Orthopaedic Surgery, Northwestern University, 259 E. Erie St. 13th Floor, Chicago, IL, 60611, USA.
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Pulik Ł, Podgajny M, Kaczyński W, Sarzyńska S, Łęgosz P. The Update on Instruments Used for Evaluation of Comorbidities in Total Hip Arthroplasty. Indian J Orthop 2021; 55:823-838. [PMID: 34188772 PMCID: PMC8192606 DOI: 10.1007/s43465-021-00357-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/08/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION It is a well-established fact that concomitant diseases can affect the outcome of total hip arthroplasty (THA). Therefore, careful preoperative assessment of a patient's comorbidity burden is a necessity, and it should be a part of routine screening as THA is associated with a significant number of complications. To measure the multimorbidity, dedicated clinical tools are used. METHODS The article is a systematic review of instruments used to evaluate comorbidities in THA studies. To create a list of available instruments for assessing patient's comorbidities, the search of medical databases (PubMed, Web of Science, Embase) for indices with proven impact on revision risk, adverse events, mortality, or patient's physical functioning was performed by two independent researchers. RESULTS The initial search led to identifying 564 articles from which 26 were included in this review. The measurement tools used were: The Charlson Comorbidity Index (18/26), Society of Anesthesiology classification (10/26), Elixhauser Comorbidity Method (6/26), and modified Frailty Index (5/26). The following outcomes were measured: quality of life and physical function (8/26), complications (10/26), mortality (8/26), length of stay (6/26), readmission (5/26), reoperation (2/26), satisfaction (2/26), blood transfusion (2/26), surgery delay or cancelation (1/26), cost of care (1/26), risk of falls (1/26), and use of painkillers (1/26). Further research resulted in a comprehensive list of eleven indices suitable for use in THA outcomes studies. CONCLUSION The comorbidity assessment tools used in THA studies present a high heterogeneity level, and there is no particular system that has been uniformly adopted. This review can serve as a help and an essential guide for researchers in the field.
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Affiliation(s)
- Łukasz Pulik
- Department of Orthopedics and Traumatology, Medical University of Warsaw, Lindley 4 St, 02-005 Warsaw, Poland
| | - Michał Podgajny
- Student Scientific Association of Reconstructive and Oncology Orthopedics of the Department of Orthopedics and Traumatology, Medical University of Warsaw, Warsaw, Poland
| | - Wiktor Kaczyński
- Student Scientific Association of Reconstructive and Oncology Orthopedics of the Department of Orthopedics and Traumatology, Medical University of Warsaw, Warsaw, Poland
| | - Sylwia Sarzyńska
- Department of Orthopedics and Traumatology, Medical University of Warsaw, Lindley 4 St, 02-005 Warsaw, Poland
| | - Paweł Łęgosz
- Department of Orthopedics and Traumatology, Medical University of Warsaw, Lindley 4 St, 02-005 Warsaw, Poland
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Does racial background influence outcomes following total joint arthroplasty? J Clin Orthop Trauma 2021; 19:139-146. [PMID: 34099973 PMCID: PMC8167263 DOI: 10.1016/j.jcot.2021.05.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/16/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The purpose of this study is to assess whether racial differences influence patient-reported outcome measures (PROMs) following primary total hip (THA) and knee (TKA) arthroplasty. METHODS We retrospectively reviewed patients who underwent primary THA or TKA from 2016 to 2020 with available PROMs. Both THA and TKA patients were separated into three groups based on their ethnicity: Caucasian, African-American, and other races. Patient demographics, clinical data, and PROMs at various time-periods were collected and compared. Demographic differences were assessed using chi-square and ANOVA. Univariate ANCOVA was utilized to compare outcomes and PROMs while accounting for demographic differences. RESULTS This study included 1999 THA patients and 1375 TKA patients. In the THA cohort, 1636 (82%) were Caucasian, 177 (9%) were African-American, and 186 (9%) were of other races. In the TKA cohort, 864 (63%) were Caucasian, 236 (17%) were African-American, and 275 (20%) were of other races. Surgical-time significantly differed between the groups that underwent THA (88.4vs.100.5vs.96.1; p < 0.001) with African-Americans requiring the longest operative time. Length-of-stay significantly differed in both THA (1.5vs.1.9vs.1.8; p < 0.001) and TKA (2.1vs.2.5vs.2.3; p < 0.001) cohorts, with African-Americans having the longest stay. Caucasians reported significantly higher PROM scores compared to non-Caucasians in both cohorts. All-cause emergency-department (ED) visits, 90-day postoperative events (readmissions&revisions), and discharge-disposition did not statistically differ in both cohorts. CONCLUSION Non-Caucasian patients demonstrated lower PROM scores when compared to Caucasian patients following TJA although the differences may not be clinically relevant. LOS was significantly longer for African-Americans in both THA and TKA cohorts. Further investigation identifying racial disparity interventions is warranted. LEVEL OF EVIDENCE Prognostic Level III.
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22
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Racial and socioeconomic disparities among patients undergoing hip arthroplasty: a New York State population analysis. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hoyler MM, Abramovitz MD, Ma X, Khatib D, Thalappillil R, Tam CW, Samuels JD, White RS. Social determinants of health affect unplanned readmissions following acute myocardial infarction. J Comp Eff Res 2021; 10:39-54. [PMID: 33438461 DOI: 10.2217/cer-2020-0135] [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] [Indexed: 12/26/2022] Open
Abstract
Background: Low socioeconomic status predicts inferior clinical outcomes in many patient populations. The effects of patient insurance status and hospital safety-net status on readmission rates following acute myocardial infarction are unclear. Materials & methods: A retrospective review of State Inpatient Databases for New York, California, Florida and Maryland, 2007-2014. Results: A total of 1,055,162 patients were included. Medicaid status was associated with 37.7 and 44.0% increases in risk-adjusted readmission odds at 30 and 90 days (p < 0.0001). Uninsured status was associated with reduced odds of readmission at both time points. High-burden safety-net status was associated with 9.6 and 9.5% increased odds of readmission at 30 and 90 days (p < 0.0003). Conclusion: Insurance status and hospital safety-net burden affect readmission odds following acute myocardial infarction.
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Affiliation(s)
- Marguerite M Hoyler
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Mark D Abramovitz
- Department of Electrical Engineering, Princeton University, Engineering Quadrangle, 41 Olden Street, Princeton, NJ 08544, USA
| | - Xiaoyue Ma
- Department of Healthcare Policy & Research, Weill Cornell Medicine, 428 East 72nd St., Suite 800A, NY 10021, USA
| | - Diana Khatib
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Richard Thalappillil
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Christopher W Tam
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Jon D Samuels
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Robert S White
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
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Mahajan SM, Mahajan A, Nguyen C, Bui J, Abbott BT, Osborne TF. Predictive models for identifying risk of readmission after index hospitalization for hip arthroplasty: A systematic review. J Orthop 2020; 22:73-85. [PMID: 32280173 PMCID: PMC7139132 DOI: 10.1016/j.jor.2020.03.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/25/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND An aging United States population profoundly impacts healthcare from both a medical and financial standpoint, especially with an increase in related procedures such as Total Hip Arthroplasty (THA). The Hospital Readmission Reduction Program and Comprehensive Care for Joint Replacement Program incentivize hospitals to decrease post-operative readmissions by correlating reimbursements with smoother care transitions, thereby decreasing hospital burden and improving quantifiable patient outcomes. Many studies have proposed predictive models built upon risk factors for predicting 30-day THA readmissions. QUESTIONS (1) Are there validated statistical models that predict 30-day readmissions for THA patients when appraised with a standards-based, reliable assessment tool?. (2) Which evidence-based factors are significant and have support across models for predicting risk of 30-day readmissions post-THA? METHODS Five major electronic databases were searched to identify studies that examined correlations between post-THA readmission and risk factors using multivariate models. We rigorously applied the PRISMA methodology and TRIPOD criteria for assessment of the prognostic studies. RESULTS We found 26 studies that offered predictive models, of which two presented models tested with validation cohorts. In addition to the many factors grouped into demographic, administrative, and clinical categories, bleeding disorder, higher ASA status, discharge disposition, and functional status appeared to have broad and significant support across the studies. CONCLUSIONS Reporting of recent predictive models establishing risk factors for 30-day THA readmissions against the current standard could be improved. Aside from building better performing models, more work is needed to follow the thorough process of undergoing calibration, external validation, and integration with existing EHR systems for pursuing their use in clinical settings. There are several risk factors that are significant in multiple models; these factors should be closely examined clinically and leveraged in future risk modeling efforts.
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Affiliation(s)
- Satish M. Mahajan
- Veterans Affairs Palo Alto Health Care System, Building 100, Office C3-125, 3801 Miranda Ave, Palo Alto, CA, 94304, USA
| | - Amey Mahajan
- C2OPS, Inc., 22031 Rae Ln, Cupertino, CA, 95014, USA
| | - Chantal Nguyen
- George Washington University School of Medicine and Health Sciences, 2300 I Street NW, Washington D.C., 20052, USA
| | - Justin Bui
- Lake Erie College of Osteopathic Medicine at Bradenton, 5000 Lakewood Ranch Boulevard, Bradenton, FL, 34211, USA
| | - Bruce T. Abbott
- University of California, Davis, Blaisdell Medical Library, 4610 X St, Sacramento, CA, 95817, USA
| | - Thomas F. Osborne
- Veterans Affairs Palo Alto Health Care System, Building 101, Office C2-139, 3801 Miranda Ave, Palo Alto, CA, 94304, USA
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Reply to Letter to the Editor: Who Cares for Total Hip Arthroplasty Complications? Rates of Readmission to a Hospital Different From the Location of the Index Procedure. J Am Acad Orthop Surg 2020; 28:e877. [PMID: 31855589 DOI: 10.5435/jaaos-d-19-00803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Letter to the Editor: Who Cares for Total Hip Arthroplasty Complications? Rates of Readmission to a Hospital Different From the Location of the Index Procedure. J Am Acad Orthop Surg 2020; 28:e875-e876. [PMID: 31855588 DOI: 10.5435/jaaos-d-19-00473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Han Q, Ren J, Tian J, Yang H, Zhang Q, Wang R, Zhao J, Han L, Li C, Yan J, Wang K, Zheng C, Han Q, Zhang Y. A nomogram based on a patient-reported outcomes measure: predicting the risk of readmission for patients with chronic heart failure. Health Qual Life Outcomes 2020; 18:290. [PMID: 32854729 PMCID: PMC7450976 DOI: 10.1186/s12955-020-01534-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 08/11/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Health-related quality of life, as evaluated by a patient-reported outcomes measure (PROM), is an important prognostic marker in patients with chronic heart failure. This study aimed to use PROM to establish an effective readmission nomogram for chronic heart failure. METHODS Using a PROM as a measurement tool, we conducted a readmission nomogram for chronic heart failure on a prospective observational study comprising of 454 patients with chronic heart failure hospitalized between May 2017 to January 2020. A Concordance index and calibration curve were used to evaluate the discriminative ability and predictive accuracy of the nomogram. A bootstrap resampling method was used for internal validation of results. RESULTS The median follow-up period in the study was 372 days. After a final COX regression analysis, the gender, income, health care, appetite-sleep, anxiety, depression, paranoia, support, and independence were identified and included in the nomogram. The nomogram showed moderate discrimination, with a concordance index of 0.737 (95% CI 0.673-0.800). The calibration curves for the probability of readmission for patients with chronic heart failure showed high consistency between the probability, as predicted, and the actual probability. CONCLUSIONS This model offers a platform to assess the risk of readmission for different populations with CHF and can assist clinicians with personalized treatment recommendations.
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Affiliation(s)
- Qiang Han
- Department of Health Statistics, School of Public Health, Shanxi Medical University, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
- Shanxi Provincial Key Laboratory of Major Diseases Risk Assessment, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
| | - Jia Ren
- Department of Cardiology, The 1st Hospital of Shanxi Medical University, 85 South Jiefang Road, Taiyuan, 030001, Shanxi Province, China
| | - Jing Tian
- Shanxi Provincial Key Laboratory of Major Diseases Risk Assessment, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
- Department of Cardiology, The 1st Hospital of Shanxi Medical University, 85 South Jiefang Road, Taiyuan, 030001, Shanxi Province, China
| | - Hong Yang
- Department of Health Statistics, School of Public Health, Shanxi Medical University, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
- Shanxi Provincial Key Laboratory of Major Diseases Risk Assessment, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
| | - Qing Zhang
- Department of Cardiology, The 1st Hospital of Shanxi Medical University, 85 South Jiefang Road, Taiyuan, 030001, Shanxi Province, China
| | - Ruoya Wang
- Department of Health Statistics, School of Public Health, Shanxi Medical University, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
- Shanxi Provincial Key Laboratory of Major Diseases Risk Assessment, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
| | - Jinghua Zhao
- Department of Health Statistics, School of Public Health, Shanxi Medical University, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
- Shanxi Provincial Key Laboratory of Major Diseases Risk Assessment, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
| | - Linai Han
- Department of Cardiology, The 1st Hospital of Shanxi Medical University, 85 South Jiefang Road, Taiyuan, 030001, Shanxi Province, China
| | - Chenhao Li
- Department of Health Statistics, School of Public Health, Shanxi Medical University, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
- Shanxi Provincial Key Laboratory of Major Diseases Risk Assessment, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
| | - Jingjing Yan
- Department of Health Statistics, School of Public Health, Shanxi Medical University, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
- Shanxi Provincial Key Laboratory of Major Diseases Risk Assessment, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
| | - Ke Wang
- Department of Health Statistics, School of Public Health, Shanxi Medical University, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
- Shanxi Provincial Key Laboratory of Major Diseases Risk Assessment, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
| | - Chu Zheng
- Department of Health Statistics, School of Public Health, Shanxi Medical University, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
- Shanxi Provincial Key Laboratory of Major Diseases Risk Assessment, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China
| | - Qinghua Han
- Department of Cardiology, The 1st Hospital of Shanxi Medical University, 85 South Jiefang Road, Taiyuan, 030001, Shanxi Province, China.
| | - Yanbo Zhang
- Department of Health Statistics, School of Public Health, Shanxi Medical University, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China.
- Shanxi Provincial Key Laboratory of Major Diseases Risk Assessment, 56 South XinJian Road, Taiyuan, 030001, Shanxi Province, China.
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Rolnick JA, Liao JM, Emanuel EJ, Huang Q, Ma X, Shan EZ, Dinh C, Zhu J, Wang E, Cousins D, Navathe AS. Spending and quality after three years of Medicare's bundled payments for medical conditions: quasi-experimental difference-in-differences study. BMJ 2020; 369:m1780. [PMID: 32554705 PMCID: PMC7298619 DOI: 10.1136/bmj.m1780] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate whether longer term participation in the bundled payments for care initiative (BPCI) for medical conditions in the United States, which held hospitals financially accountable for all spending during an episode of care from hospital admission to 90 days after discharge, was associated with changes in spending, mortality, or health service use. DESIGN Quasi-experimental difference-in-differences analysis. SETTING US hospitals participating in bundled payments for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), or pneumonia, and propensity score matched to non-participating hospitals. PARTICIPANTS 238 hospitals participating in the Bundled Payments for Care Improvement initiative (BPCI) and 1415 non-BPCI hospitals. 226 BPCI hospitals were matched to 700 non-BPCI hospitals. MAIN OUTCOME MEASURES Primary outcomes were total spending on episodes and death 90 days after discharge. Secondary outcomes included spending and use by type of post-acute care. BPCI and non-BPCI hospitals were compared by patient, hospital, and hospital market characteristics. Market characteristics included population size, competitiveness, and post-acute bed supply. RESULTS In the 226 BPCI hospitals, episodes of care totaled 261 163 in the baseline period and 93 562 in the treatment period compared with 211 208 and 78 643 in the 700 matched non-BPCI hospitals, respectively, with small differences in hospital and market characteristics after matching. Differing trends were seen for some patient characteristics (eg, mean age change -0.3 years at BPCI hospitals v non- BPCI hospitals, P<0.001). In the adjusted analysis, participation in BPCI was associated with a decrease in total episode spending (-1.2%, 95% confidence interval -2.3% to -0.2%). Spending on care at skilled nursing facilities decreased (-6.3%, -10.0% to -2.5%) owing to a reduced number of facility days (-6.2%, -9.8% to -2.6%), and home health spending increased (4.4%, 1.4% to 7.5%). Mortality at 90 days did not change (-0.1 percentage points, 95% confidence interval -0.5 to 0.2 percentage points). CONCLUSIONS In this longer term evaluation of a large national programme on medical bundled payments in the US, participation in bundles for four common medical conditions was associated with savings at three years. The savings were generated by practice changes that decreased use of high intensity care after hospital discharge without affecting quality, which also suggests that bundles for medical conditions could require multiple years before changes in savings and practice emerge.
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Affiliation(s)
- Joshua A Rolnick
- Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- National Clinician Scholars Program,Philadelphia, PA, USA
| | - Joshua M Liao
- University of Washington School of Medicine, Seattle, WA USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
| | - Ezekiel J Emanuel
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Qian Huang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Xinshuo Ma
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Eric Z Shan
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Claire Dinh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Deborah Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Amol S Navathe
- Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
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Rozental O, Ma X, Weinberg R, Gadalla F, Essien UR, White RS. Disparities in mortality after abdominal aortic aneurysm repair are linked to insurance status. J Vasc Surg 2020; 72:1691-1700.e5. [PMID: 32173191 DOI: 10.1016/j.jvs.2020.01.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 01/11/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The objective of this study was to determine differences in mortality after abdominal aortic aneurysm (AAA) repair based on insurance type. METHODS In this retrospective cohort study, data from all-payer patients in nonpsychiatric hospitals in New York, Maryland, Florida, Kentucky, and California from January 2007 to December 2014 (excluding California, ending December 2011) were extracted from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. There were 90,102 patients ≥18 years old with available insurance data who underwent open AAA repair or endovascular aneurysm repair (EVAR) identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes 3844, 3925, and 3971. EVAR patients were identified using the procedure code 3971, and the remainder of cases were categorized as open. Patients were divided into cohorts by insurance type as Medicare, Medicaid, uninsured (self-pay/no charge), other, or private insurance. Patients were further stratified for subgroup analyses by procedure type. Unadjusted rates of in-hospital mortality, the primary outcome, as well as secondary outcomes, such as surgical urgency, 30-day and 90-day readmissions, length of stay, total charges, and postoperative complications, were examined by insurance type. Adjusted odds ratios (ORs) for in-hospital mortality were calculated using multivariate logistic regression models fitted to the data. The multivariate models included patient-, surgical-, and hospital-specific factors with bivariate baseline testing suggestive of association with insurance status in addition to variables that were selected a priori. RESULTS Medicaid and uninsured patients had the highest rates of mortality relative to private insurance beneficiaries in all cohorts. Medicaid patients incurred a 47% increase in the odds of mortality, the highest among the insured, after all AAA repairs (OR, 1.47; 95% confidence interval [CI], 1.23-1.76), whereas uninsured patients experienced a 102% increase in the odds of mortality (OR, 2.02; 95% CI, 1.54-2.67). Subgroup analyses for open AAA repair and EVAR corroborated that Medicaid insurance (open repair OR, 1.37 [95% CI, 1.14-1.64]; EVAR OR, 2.06 [95% CI, 1.40-3.04]) and uninsured status (open repair OR, 1.85 [95% CI, 1.35-2.54]; EVAR OR, 2.96 [95% CI, 1.82-4.81]) were associated with the highest odds of mortality after both procedures separately. CONCLUSIONS This study demonstrates that Medicaid insurance and uninsured status are associated with higher unadjusted rates and adjusted ORs for in-hospital mortality after AAA repair relative to private insurance status. Primary payer status therefore serves as an independent predictor of the risk of death subsequent to AAA surgical interventions.
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Affiliation(s)
- Olga Rozental
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Xiaoyue Ma
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY
| | - Roniel Weinberg
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Farida Gadalla
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Utibe R Essien
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa; Center for Healthy Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pa
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY.
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Feng TR, Hoyler MM, Ma X, Rong LQ, White RS. Insurance Status and Socioeconomic Markers Affect Readmission Rates After Cardiac Valve Surgery. J Cardiothorac Vasc Anesth 2020; 34:668-678. [DOI: 10.1053/j.jvca.2019.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/29/2019] [Accepted: 08/02/2019] [Indexed: 11/11/2022]
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Brumm J, White RS, Arroyo NS, Gaber-Baylis LK, Gupta S, Turnbull ZA, Mehta N. Sickle Cell Disease is Associated with Increased Morbidity, Resource Utilization, and Readmissions after Common Abdominal Surgeries: A Multistate Analysis, 2007-2014. J Natl Med Assoc 2020; 112:198-208. [PMID: 32089275 DOI: 10.1016/j.jnma.2020.01.001] [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: 02/21/2019] [Revised: 01/15/2020] [Accepted: 01/23/2020] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Sickle cell disease (SCD), the most commonly inherited hemoglobinopathy in the United States, increases the likelihood of postoperative complications, resulting in higher costs and readmissions. We used a retrospective cohort study to explore SCD's influence on postoperative complications and readmissions after cholecystectomy, appendectomy, and hysterectomy. METHODS We used an administrative database's 2007-2014 data from California, Florida, New York, Maryland, and Kentucky. RESULTS 1,934,562 patients aged ≥18 years were included. Compared to non-SCD patients, SCD patients experienced worse outcomes: increased odds of blood transfusion and major and minor complications, higher adjusted odds of 30- and 90-day readmissions, longer length of stay, and higher total hospital charges. CONCLUSION Sickle cell disease patients are at high risk for poor outcomes based on their demographic characteristics. Therefore, perioperative physicians including hematologists, anesthesiologists, and surgeons need to take this knowledge into consideration for management and counselling of SCD patients on the risks of surgery and recovery.
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Affiliation(s)
- John Brumm
- NewYork-Presbyterian Hospital - Weill Cornell Medicine, USA
| | - Robert S White
- NewYork-Presbyterian Hospital - Weill Cornell Medicine, USA.
| | - Noelle S Arroyo
- Weill Cornell Medicine Center for Perioperative Outcomes, USA
| | | | - Soham Gupta
- Weill Cornell Medicine Center for Perioperative Outcomes, USA
| | | | - Neel Mehta
- NewYork-Presbyterian Hospital - Weill Cornell Medicine, USA
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Park HS, White RS, Ma X, Lui B, Pryor KO. Social determinants of health and their impact on postcolectomy surgery readmissions: a multistate analysis, 2009–2014. J Comp Eff Res 2019; 8:1365-1379. [DOI: 10.2217/cer-2019-0114] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Aim: To examine the effect of race/ethnicity, insurance status and median household income on postoperative readmissions following colectomy. Patients & methods: Multivariate analysis of hospital discharge data from California, Florida, Maryland and New York from 2009 to 2014. Primary outcomes included adjusted odds of 30- and 90-day readmissions following colectomy by race, insurance status and median income quartile. Results: Total 330,840 discharges included. All 30-day readmissions were higher for black patients (adjusted odds ratio [aOR]: 1.07). Both 30- and 90-day readmissions were higher for Medicaid (aOR: 1.30 and 1.26) and Medicare (aOR: 1.30 and 1.29). The 30- and 90-day readmissions were lower in the highest income quartiles. Conclusion: Race, insurance status and median household income are all independent predictors of disparity in readmissions following colectomy.
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Affiliation(s)
- Hyun S Park
- Weill Cornell Medicine/New York Presbyterian Hospital, Department of Anesthesiology, 525 East 68th Street, Box 124, New York, NY 10065, USA
| | - Robert S White
- Weill Cornell Medicine/New York Presbyterian Hospital, Department of Anesthesiology, 525 East 68th Street, Box 124, New York, NY 10065, USA
| | - Xiaoyue Ma
- Weill Cornell Medicine, Division of Biostatistics & Epidemiology, Department of Healthcare Policy & Research, 402 East 67th Street, Box 74, New York, NY 10065, USA
| | - Briana Lui
- Weill Cornell Medicine/New York Presbyterian Hospital, Department of Anesthesiology, 525 East 68th Street, Box 124, New York, NY 10065, USA
| | - Kane O Pryor
- Weill Cornell Medicine/New York Presbyterian Hospital, Department of Anesthesiology, 525 East 68th Street, Box 124, New York, NY 10065, USA
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Hart A, Wyles CC, Abdel MP, Perry KI, Pagnano MW, Taunton MJ. Thirty-Day Major and Minor Complications Following Total Hip Arthroplasty-A Comparison of the Direct Anterior, Lateral, and Posterior Approaches. J Arthroplasty 2019; 34:2681-2685. [PMID: 31358324 DOI: 10.1016/j.arth.2019.06.046] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 06/18/2019] [Accepted: 06/20/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The choice of surgical approach during total hip arthroplasty (THA) remains highly controversial. The aim of the present study was to compare 30-day major and minor complications, following primary THA between the direct anterior, lateral, and posterior approaches. METHODS Our hospital performs primary THAs using all 3 aforementioned approaches based on surgeon preference. Patients who underwent primary THA from August 2010 to August 2017 were identified using our institution's total joint registry, and their data were combined with prospectively collected data from the National Surgical Quality Improvement Program database (which evaluates a random sample of approximately 20% of all surgical patients in our hospital). Baseline characteristics, operative variables, and postoperative complications were then compared between the three groups. RESULTS The analysis comprised 1967 primary THAs (1913 patients), whereby 56%, 29%, and 15% were performed through a posterior, lateral, and direct anterior approach, respectively. Thirty-day major and minor complications occurred in 3.9% and 9.4% of surgeries, respectively. After adjusting for baseline patient characteristics, there was no significant difference in major or minor perioperative complications between the 3 approaches. CONCLUSIONS This study compared perioperative complications between the 3 most commonly used approaches for THA utilizing a synthesis of our institutional total joint registry and high-quality National Surgical Quality Improvement Program data. Thirty-day major and minor complications were similar regardless of the surgical approach employed, which may help surgeons and patients simplify the multiple considerations taken into account when deciding on surgical approach for primary THA. LEVEL OF EVIDENCE Therapeutic, Level III.
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Affiliation(s)
- Adam Hart
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Cody C Wyles
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kevin I Perry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mark W Pagnano
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Perlstein MD, Gupta S, Ma X, Rong LQ, Askin G, White RS. Abdominal Aortic Aneurysm Repair Readmissions and Disparities of Socioeconomic Status: A Multistate Analysis, 2007-2014. J Cardiothorac Vasc Anesth 2019; 33:2737-2745. [DOI: 10.1053/j.jvca.2019.03.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 01/14/2023]
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La M, Tangel V, Gupta S, Tedore T, White RS. Hospital safety net burden is associated with increased inpatient mortality and postoperative morbidity after total hip arthroplasty: a retrospective multistate review, 2007-2014. Reg Anesth Pain Med 2019; 44:rapm-2018-100305. [PMID: 31229962 DOI: 10.1136/rapm-2018-100305] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/15/2019] [Accepted: 05/20/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Total hip arthroplasty (THA) is one of the most widely performed surgical procedures in the USA. Safety net hospitals, defined as hospitals with a high proportion of cases billed to Medicaid or without insurance, deliver a significant portion of their care to vulnerable populations, but little is known about the effects of a hospital's safety net burden and its role in healthcare disparities and outcomes following THA. We quantified safety net burden and examined its impact on in-hospital mortality, complications and length of stay (LOS) in patients who underwent THA. METHODS We analyzed 500 189 patient discharge records for inpatient primary THA using data from the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland and Kentucky from 2007 to 2014. We compared patient demographics, present-on-admission comorbidities and hospital characteristics by hospital safety net burden status. We estimated mixed-effect generalized linear models to assess hospital safety burden status' effect on in-hospital mortality, patient complications and LOS. RESULTS Patients undergoing THA at a hospital with a high or medium safety net burden were 38% and 30% more likely, respectively, to die in-hospital compared with those in a low safety net burden hospital (high adjusted OR: 1.38, 95% CI 1.10 to 1.73; medium adjusted OR: 1.30, 95% CI 1.07 to 1.57). Compared with patients treated in hospitals with a low safety net burden, patients treated in high safety net hospitals were more likely to develop a postoperative complication (adjusted OR: 1.11, 95% CI 1.00 to 1.24) and require a longer LOS (adjusted IRR: 1.06, 95% CI 1.05, 1.07). CONCLUSIONS Our study supports our hypothesis that patients who underwent THA at hospitals with higher safety net burden have poorer outcomes than patients at hospitals with lower safety net burden.
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Affiliation(s)
- Melvin La
- Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medicine, New York City, New York, USA
| | - Virginia Tangel
- Center for Perioperative Outcomes, Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
| | - Soham Gupta
- Center for Perioperative Outcomes, Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
| | - Tiffany Tedore
- Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medicine, New York City, New York, USA
| | - Robert S White
- Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medicine, New York City, New York, USA
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Patel NH, Parikh SS, Bloom JB, Schulman A, Wagmaister J, Fullerton S, Phillips JL, Choudhury M, Eshghi M. Contemporary Trends in Percutaneous Nephrolithomy Across New York State: A Review of the Statewide Planning and Research Cooperative System. J Endourol 2019; 33:699-703. [PMID: 31179737 DOI: 10.1089/end.2019.0115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction and Objectives: Percutaneous nephrolithotomy (PCNL) is a complex multistep surgery that has shown a steady increase in use for the past decade in the United States. We sought to evaluate the trends and factors associated with PCNL usage across New York State (NYS). Our goal was to characterize patient demographics and socioeconomic factors across high-, medium-, and low-volume institutions. Materials and Methods: We searched the NYS, Statewide Planning and Research Cooperative System (SPARCS) database from 2006 to 2014 using ICD-9 Procedure Codes 55.04 (percutaneous nephrostomy with fragmentation) for all hospital discharges. Patient demographics including age, gender, race, insurance status, and length of hospital stay were obtained. We characterized each hospital as a low-, medium-, or high-volume center by year. Patient and hospital demographics were compared and reported using chi-square analysis and Student's t-test for categorical and continuous variables, respectively, with statistical significance as a p-value of <0.05. Results: We identified a total of 4576 procedures performed from 2006 to 2014 at a total of 77 hospitals in NYS (Table 1). Total PCNL volume performed across all NYS hospitals increased in the past decade, with the greatest number of procedures performed in 2012 to 2013. Low-volume institutions were more likely to provide care to minority populations (21.4% vs 17.3%, p < 0.001) and those with Medicaid (25.5% vs 21.5%, p < 0.001). High-volume institutions provided care to patients with private insurance (42.1% vs 34.0%, p < 0.001) and had a shorter length of stay (3.3 days vs 4.1 days, p < 0.001). Conclusion: Our data provide insight into the patient demographics of those treated at high-, medium-, and low-volume hospitals for PCNL across NYS. Significant differences in race, insurance status, and length of stay were noted between low- and high-volume institutions, indicating that racial and socioeconomic factors play a role in access to care at high-volume centers.
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Affiliation(s)
- Neel H Patel
- Department of Urology, New York Medical College, Valhalla, New York
| | - Suraj S Parikh
- Department of Urology, New York Medical College, Valhalla, New York
| | - Jonathan B Bloom
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Ariel Schulman
- Department of Urology, Maimonides Medical Center, Brooklyn, New York
| | | | - Sean Fullerton
- Department of Urology, New York Medical College, Valhalla, New York
| | - John L Phillips
- Department of Urology, New York Medical College, Valhalla, New York
| | | | - Majid Eshghi
- Department of Urology, New York Medical College, Valhalla, New York
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Singh JA, Cleveland JD. Insurance Payer Type and Patient Income Are Associated with Outcomes after Total Shoulder Arthroplasty. J Rheumatol 2019; 47:589-596. [PMID: 31154417 DOI: 10.3899/jrheum.190287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To assess the independent association of insurance and patient income with total shoulder arthroplasty (TSA) outcomes. METHODS We used the 1998-2014 US National Inpatient Sample. We used multivariable-adjusted logistic regression to examine whether insurance type and the patient's median household income (based on postal code) were independently associated with healthcare use (discharge destination, hospital stay duration, total hospital charges) and in-hospital complications post-TSA based on the diagnostic codes (fracture, infection, transfusion, or revision surgery). We calculated the OR and 95% CI. RESULTS Among the 349,046 projected TSA hospitalizations, the mean age was 68.6 years, 54% were female, and 73% white. Compared to private insurance, Medicaid and Medicare (government insurance) users were associated with significantly higher adjusted OR (95% CI) of (1) discharge to a rehabilitation facility, 2.16 (1.72-2.70) and 2.27 (2.04-2.52); (2) hospital stay > 2 days, 1.65 (1.45-1.87) and 1.60 (1.52-1.69); and (3) transfusion, 1.35 (1.05-1.75) and 1.39 (1.24-1.56), respectively. Medicaid was associated with a higher risk of fracture [1.74 (1.07-2.84)] and Medicare user with a higher risk of infection [2.63 (1.24-5.57)]; neither were associated with revision. Compared to the highest income quartile, the lowest income quartile was significantly associated with (OR, 95% CI): (1) discharge to a rehabilitation facility (0.89, 0.83-0.96); (2) hospital stay > 2 days (0.84, 0.80-0.89); (3) hospital charges above the median (1.19, 1.14-1.25); (4) transfusion (0.73, 0.66-0.81); and (5) revision (0.49, 0.30-0.80), but not infection or fracture. CONCLUSION This information can help to risk-stratify patients post-TSA. Future assessments of modifiable mediators of these complications are needed.
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Affiliation(s)
- Jasvinder A Singh
- From the Birmingham Veterans Affairs (VA) Medical Center; Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA. .,J.A. Singh, MBBS, MPH, Birmingham VA Medical Center, and Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; J.D. Cleveland, MS, Department of Medicine at the School of Medicine, University of Alabama at Birmingham.
| | - John D Cleveland
- From the Birmingham Veterans Affairs (VA) Medical Center; Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA.,J.A. Singh, MBBS, MPH, Birmingham VA Medical Center, and Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; J.D. Cleveland, MS, Department of Medicine at the School of Medicine, University of Alabama at Birmingham
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Chen Y, White RS, Tangel V, Noori SA, Gaber-Baylis LK, Mehta ND, Pryor KO. Sickle cell disease and readmissions rates after lower extremity arthroplasty: a multistate analysis 2007–2014. J Comp Eff Res 2019; 8:403-422. [DOI: 10.2217/cer-2018-0098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Aim: To compare readmission rates between patients with sickle cell disease (SCD) and non-sickle cell disease undergoing total hip and knee arthroplasty (THA and TKA). Methods: Identified adult patients who underwent THA or TKA from 2007 to 2014 in California, Florida, New York, Maryland and Kentucky using a multistate database. Outcomes were 30- and 90-day readmission rates, mortality, complications, length of stay and hospital charges. Logistic regression models were used for analysis. Results: Compared with non-sickle cell disease patients following TKA and THA, SCD patients had higher odds of 30- (odds ratio [OR]: 3.79) and 90-day readmissions (OR: 4.15), mortality (OR: 6.54), more complications, longer length of stay, and higher total charges. Conclusion: Following TKA and THA, SCD is associated with higher readmissions and worse outcomes.
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Affiliation(s)
- Yuefan Chen
- Department of Anesthesiology, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA
| | - Robert S White
- Department of Anesthesiology, New York-Presbyterian Hospital/Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA
| | - Virginia Tangel
- Center for Perioperative Outcomes, Department of Anesthesiology, Weill Cornell Medicine, 428 East 72nd St, Ste 800A, New York, NY 10021, USA
| | - Selaiman A Noori
- Department of Pain Management, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, C-25, Cleveland, OH 44195, USA
| | - Licia K Gaber-Baylis
- Center for Perioperative Outcomes, Department of Anesthesiology, Weill Cornell Medicine, 428 East 72nd St, Ste 800A, New York, NY 10021, USA
| | - Neel D Mehta
- Department of Anesthesiology, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA
| | - Kane O Pryor
- Department of Anesthesiology, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA
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Socioeconomic, Racial, and Ethnic Disparities in Postpartum Readmissions in Patients with Preeclampsia: a Multi-state Analysis, 2007–2014. J Racial Ethn Health Disparities 2019; 6:806-820. [DOI: 10.1007/s40615-019-00580-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/27/2019] [Accepted: 03/08/2019] [Indexed: 10/27/2022]
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Chen SA, White RS, Tangel V, Nachamie AS, Witkin LR. Sociodemographic Characteristics Predict Readmission Rates After Lumbar Spinal Fusion Surgery. PAIN MEDICINE 2019; 21:364-377. [DOI: 10.1093/pm/pny316] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Stephanie A Chen
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Virginia Tangel
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | | | - Lisa R Witkin
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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Plate JF, Ryan SP, Goltz DE, Howell CB, Bolognesi MP, Seyler TM. Medicaid Insurance Correlates With Increased Resource Utilization Following Total Hip Arthroplasty. J Arthroplasty 2019; 34:255-259. [PMID: 30396744 DOI: 10.1016/j.arth.2018.10.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 09/29/2018] [Accepted: 10/09/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND With increased restraints and efforts to contain costs in total hip arthroplasty (THA), an emphasis has been placed on risk stratification. The purpose of this study was to determine whether Medicaid patients have increased resource utilization (including 90-day emergency department [ED] visits and readmissions) compared to Medicare or commercial insurance carriers. The study hypothesized that the Medicaid population would represent a high-risk cohort with increased resource utilization. METHODS The institutional database was retrospectively queried for primary THAs from 2013 to 2017 based on Current Procedural Terminology codes and patients undergoing revision surgery were excluded. Demographic information including age, sex, and body mass index (BMI) and medical comorbidities including American Society of Anesthesiologists (ASA) scores were evaluated. Patients were stratified by insurance type and length of stay (LOS), and 90-day ED visits and 90-day readmissions were assessed in univariable and multivariable analysis. RESULTS A total of 3674 primary THA patients were included in the analysis (including 116 with Medicaid, 1713 with Medicare, and 1845 with other insurance providers). Medicaid patients had significantly higher ASA scores (P < .001) and BMI (P < .001), with corresponding increase in procedure duration (115 vs 99 vs 105 minutes; P < .001). They had a prolonged LOS (2.5 vs 2.5 vs 1.5 days; P < .001) compared with other insurances, but similar to Medicare patients. Following discharge, in multivariable analysis controlling for age, BMI, and ASA score, Medicare patients were significantly more likely to return to the ED (odds ratio, 3.15; 95% confidence interval, 1.88-5.27; P < .001) and be readmitted (odds ratio, 2.46; 95% confidence interval, 1.26-4.81; P = .009). CONCLUSION Medicaid patients represent a higher risk cohort with increased resource utilization perioperatively, including longer LOS, and more 90-day ED visits and readmissions. This should be considered in outcome assessments and alternative expectations for the episode of care should be set for this population.
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Affiliation(s)
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University, Durham, NC
| | - Daniel E Goltz
- Department of Orthopaedic Surgery, Duke University, Durham, NC
| | - Claire B Howell
- Department of Orthopaedic Surgery, Duke University, Durham, NC
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