The effects of the Affordable Care Act on access and outcomes of colon surgery

The Rich Get Richer: The Matthew Effect in Open Payments

INTRODUCTION

The Matthew Effect refers to a pattern of accumulated advantage, specifically how social status can lead to increased wealth and recognition. The Physician Payments Sunshine Act of the Affordable Care Act requires industry payments and the affiliated hospital to be publicly available through the Open Payments Database (OPD). The US News and World Report (USNWR) publishes a ranking of best medical school (research) programs yearly. The Blue Ridge Institute for Medical Research (BRIMR) ranks medical schools annually by the amount of funding from the National Institutes of Health (NIH). Whether medical school-affiliated hospitals with higher social ranking and more NIH funding receive more industrial support is unknown. This study aims to evaluate the relationship between open payment of medical school-affiliated hospitals and USNWR and BRIMR ranking.

METHODS

We performed a cross-sectional analysis of the OPD for the fiscal year of 2021. Hospital industry payment information was collected for affiliated hospitals in general and research categories. NIH funding data and program rankings were collected from BRIMR and USNWR, respectively. All data were collected for the fiscal year of 2021. The open payments of schools ranked in the top 50 for USNWR (n = 50) and BRIMR (n = 49) were compared to the schools not ranked in the top 50 using SPSS with chi-squared and Mann-Whitney U tests. A multivariate linear regression was performed to evaluate the association between open payments, USNWR ranking, and BRIMR ranking.

RESULTS

A total of 91 medical schools were included in this study. The top 50 ranked medical schools by BRIMR were found to have a higher median of total open payment ($5,652,628 versus $2,558,372, P < 0.001), open payment in research ($4,707,297 versus $1,992,597, P = 0.003), and general open payment ($1,083,018 versus $392,045, P < 0.001). When ranked by USNWR, the top 50 ranked medical schools were found similarly to have a higher median of total open payment (P < 0.001), open payment in research (P < 0.001), and general open payment (P < 0.001). USNWR ranking was an independent predictor of more total open payment (Coefficient 0.016, 95% confidence interval 0.002-0.029, P = 0.026) and research open payment (coefficient 0.018, 95% confidence interval 0.002-0.034, P = 0.028). USNWR ranking was not found to predict general open payments. BRIMR ranking was not associated with open payment in total, research, or general.

CONCLUSIONS

Hospital open payments were associated with the social reputation of their medical schools. NIH funding was not associated with open payments. A Matthew effect exists in current industry payments to medical school-affiliated hospitals.

Medicaid Expansion and Postoperative Mortality in Women with Gynecologic Cancer: A Difference-in-Difference Analysis

BACKGROUND

The association between Medicaid expansion and postoperative mortality after surgery for gynecologic cancer is unknown. Our objective was to compare 30- and 90-day postoperative mortality after gynecologic cancer surgery before and after 2014 in states that did and did not expand Medicaid.

METHODS

We searched the National Cancer Database for women aged 40-64 years old between 2010 and 2016 who underwent surgery for a primary gynecologic malignancy. We used pre/post and quasi-experimental difference-in-difference (DID) multivariable logistic regressions to evaluate mortality pre-2014 (2010-2013) and post-2014 (2014-2016) for states that did and did not expand Medicaid in January 2014. We completed univariable logistic regressions for covariates of interest.

RESULTS

Among 169,731 women, 30-day postoperative mortality in expansion states after 2014 significantly decreased for endometrial cancer (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.26-0.67) and ovarian cancer (OR 0.67, 95% CI 0.46-0.99) and increased for cervical cancer (OR 3.82, 95% CI 1.12-13.01). Compared with non-expansion states, expansion states had improved 30-day postoperative mortality for endometrial cancer after 2014 (DID OR 0.54, 95% CI 0.31-0.96). Univariable analysis demonstrated improved 30-day postoperative mortality for Black women with endometrial cancer in expansion states (DID OR 0.22, 95% CI 0.05-0.95). There was improved 90-day postoperative mortality for endometrial cancer in expansion states (OR 0.66, 95% CI 0.50-0.85), and improved 90-day postoperative mortality for Midwestern women with ovarian cancer in expansion states on univariable analysis (DID OR 0.48, 95% CI 0.26-0.91).

CONCLUSIONS

State Medicaid legislation was associated with improved postoperative survival in women with endometrial cancer and subgroups of women with endometrial and ovarian cancer.

Racial disparities in the utilization of parathyroidectomy among patients with primary hyperparathyroidism: Evidence from a nationwide analysis of Medicare claims

BACKGROUND

Among patients with primary hyperparathyroidism, parathyroidectomy offers a chance of cure and mitigation of disease-related complications. The impact of race/ethnicity on referral and utilization of parathyroidectomy has not been fully explored.

METHODS

Population-based, retrospective cohort study using 100% Medicare claims from beneficiaries with primary hyperparathyroidism from 2006 to 2016. Associations of race/ethnicity with disease severity, surgeon evaluation, and subsequent parathyroidectomy were analyzed using adjusted multivariable logistic regression models.

RESULTS

Among 210,206 beneficiaries with primary hyperparathyroidism, 63,136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Black patients were more likely than other races/ethnicities to have stage 3 chronic kidney disease (10.8%) but had lower prevalence of osteoporosis and nephrolithiasis compared to White patients, Black and Hispanic patients were more likely to have been hospitalized for primary hyperparathyroidism-associated conditions (White 4.8%, Black 8.1%, Hispanic 5.8%; P < .001). Patients who were White and met operative criteria were more likely to undergo parathyroidectomy than Black, Hispanic, or Asian patients (White 30.5%, Black 23.0%, Hispanic 21.4%, Asian 18.7%; P < .001). Black and Hispanic patients had lower adjusted odds of being evaluated by a surgeon (odds ratios 0.71 [95% confidence interval 0.69-0.74], 0.68 [95% confidence interval 0.61-0.74], respectively) and undergoing parathyroidectomy if evaluated by a surgeon (odds ratios 0.72 [95% confidence interval 0.68-0.77], 0.82 [95% confidence interval 0.67-0.99]). Asian race was associated with lower adjusted odds of being evaluated by a surgeon (odds ratio 0.64 [95% confidence interval 0.57-0.71]), but no difference in odds of parathyroidectomy.

CONCLUSION

Racial/ethnic disparities exist in the management of primary hyperparathyroidism among older adults. Determining the factors that account for this disparity require urgent attention to achieve parity in the management of primary hyperparathyroidism.