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Homer AS, Kasthuri VS, Homer BJ, Jain R, Gall EK, Noonan KY. The Association Between Medicaid Expansion and Disparities in Vestibular Schwannoma Incidence. Laryngoscope 2024. [PMID: 38837793 DOI: 10.1002/lary.31517] [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: 01/15/2024] [Revised: 03/26/2024] [Accepted: 04/24/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVES The effect of Medicaid expansion as a part of the Affordable Care Act on vestibular schwannoma (VS) incidence overall and in marginalized populations has not yet been elucidated. The goal of this study was to determine if Medicaid expansion was associated with increases in VS incidence overall, as well as in patients of non-white race or in counties of low socioeconomic status (SES). METHODS We performed a difference-in-difference (DiD) analysis from January 1st 2010-December 31st 2017 utilizing the Surveillance, Epidemiology, and End Results (SEER) database. Our DiD method compared the change in VS rate between counties that did and did not expand Medicaid among patients of white and non-white race, in low and high SES counties, before and after expansion. RESULTS The study included 17,312 cases across 1020 counties. Medicaid expansion was associated with a 15% increase (incidence rate ratio 95% CI: [11%, 19]) in VS incidence. White populations saw a 10% increase (CI: [1.06, 1.19]), Black populations saw a 20% increase (CI: [1.10, 1.29]), and patients of other races saw a 44% increase in incidence associated with expansion (CI: [1.21, 1.70]). Low SES counties saw an increase in incidence 1.12 times higher than that of high SES counties (CI:[1.04, 1.20]). CONCLUSION Medicaid expansion was associated with increases in VS incidence across populations. Furthermore, this increase was more evident in disadvantaged populations, such as patients of non-white race and those from low SES counties. These findings emphasize the impact of Medicaid expansion on healthcare utilization for VS diagnosis. LEVEL OF EVIDENCE Step/Level 3-Retrospective Cohort Study Laryngoscope, 2024.
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Affiliation(s)
- Alexander S Homer
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Viknesh S Kasthuri
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Benjamin J Homer
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Rishubh Jain
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Emily K Gall
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, U.S.A
| | - Kathryn Y Noonan
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, U.S.A
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2
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Williams SL, Benedict K, Toda M. Fungal Infections and Social Determinants of Health: Using Data to Identify Disparities. CURRENT FUNGAL INFECTION REPORTS 2024; 18:88-94. [PMID: 39380623 PMCID: PMC11457536 DOI: 10.1007/s12281-024-00494-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 10/10/2024]
Abstract
Purpose of Review Fungal diseases disproportionately affect certain demographic populations, but few studies have thoroughly investigated the drivers of those disparities. We summarize data sources that can be considered to explore potential associations between fungal diseases and social determinants of health in the United States. Recent Findings Sociodemographic disparities are apparent in fungal diseases, and social determinants of health (e.g., income, living conditions, and healthcare access) may be associated with increased risk of infection, severe disease, and poor health outcomes. Summary Numerous data sources are available in the United States to analyze the potential association between fungal diseases and underlying social determinants of health. Each source has benefits and limitations that should be considered in the development of analysis plans. Inherent challenges to all fungal disease data (e.g., underdiagnosis, underreporting, and inability to detect people who do not seek medical care) should be noted and accounted for in interpretation of results.
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Affiliation(s)
- Samantha L. Williams
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop H24-11, Atlanta, GA, USA
| | - Kaitlin Benedict
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop H24-11, Atlanta, GA, USA
| | - Mitsuru Toda
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop H24-11, Atlanta, GA, USA
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Elmohr MM, Javed Z, Dubey P, Jordan JE, Shah L, Nasir K, Rohren EM, Lincoln CM. Social Determinants of Health Framework to Identify and Reduce Barriers to Imaging in Marginalized Communities. Radiology 2024; 310:e223097. [PMID: 38376404 PMCID: PMC10902599 DOI: 10.1148/radiol.223097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 09/20/2023] [Accepted: 09/25/2023] [Indexed: 02/21/2024]
Abstract
Social determinants of health (SDOH) are conditions influencing individuals' health based on their environment of birth, living, working, and aging. Addressing SDOH is crucial for promoting health equity and reducing health outcome disparities. For conditions such as stroke and cancer screening where imaging is central to diagnosis and management, access to high-quality medical imaging is necessary. This article applies a previously described structural framework characterizing the impact of SDOH on patients who require imaging for their clinical indications. SDOH factors can be broadly categorized into five sectors: economic stability, education access and quality, neighborhood and built environment, social and community context, and health care access and quality. As patients navigate the health care system, they experience barriers at each step, which are significantly influenced by SDOH factors. Marginalized communities are prone to disparities due to the inability to complete the required diagnostic or screening imaging work-up. This article highlights SDOH that disproportionately affect marginalized communities, using stroke and cancer as examples of disease processes where imaging is needed for care. Potential strategies to mitigate these disparities include dedicating resources for clinical care coordinators, transportation, language assistance, and financial hardship subsidies. Last, various national and international health initiatives are tackling SDOH and fostering health equity.
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Affiliation(s)
- Mohab M. Elmohr
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
| | - Zulqarnain Javed
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
| | - Prachi Dubey
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
| | - John E. Jordan
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
| | - Lubdha Shah
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
| | - Khurram Nasir
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
| | - Eric M. Rohren
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
| | - Christie M. Lincoln
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
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Abreu AA, Meier J, Alterio RE, Farah E, Bhat A, Wang SC, Porembka MR, Mansour JC, Yopp AC, Zeh HJ, Polanco PM. Association of race, demographic and socioeconomic factors with failure to rescue after hepato-pancreato-biliary surgery in the United States. HPB (Oxford) 2024; 26:212-223. [PMID: 37863740 DOI: 10.1016/j.hpb.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/12/2023] [Accepted: 10/01/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND We aimed to describe the association of patient-related factors such as race, socioeconomic status, and insurance on failure to rescue (FTR) after hepato-pancreato-biliary (HPB) surgeries. METHODS Using the National Inpatient Sample, we analyzed 98,788 elective HPB surgeries between 2004 and 2017. Major and minor complications were identified using ICD9/10 codes. We evaluated mortality rates and FTR (inpatient mortality after major complications). We used multivariate logistic regression analysis to assess racial, socioeconomic, and demographic factors on FTR, adjusting for covariates. RESULTS Overall, 43 % of patients (n = 42,256) had pancreatic operations, 36% (n = 35,526) had liver surgery, and 21% (n = 21,006) had biliary interventions. The overall major complication rate was 21% (n = 20,640), of which 8% (n = 1655) suffered FTR. Factors independently associated with increased risk for FTR were male sex, older age, higher Charlson Comorbidity Index, Hispanic ethnicity, Asian or other race, lower income quartile, Medicare insurance, and southern region hospitals. CONCLUSIONS Medicare insurance, male gender, Hispanic ethnicity, and lower income quartile were associated with increased risk for FTR. Efforts should be made to improve the identification and subsequent treatment of complications for those at high risk of FTR.
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Affiliation(s)
- Andres A Abreu
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jennie Meier
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rodrigo E Alterio
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Emile Farah
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Archana Bhat
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sam C Wang
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew R Porembka
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John C Mansour
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Adam C Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Patricio M Polanco
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Glaus H, Drewniak D, März JW, Biller-Andorno N. Blacklisting Health Insurance Premium Defaulters: Is Denial of Medical Care Ethically Justifiable? HEALTH CARE ANALYSIS 2023; 31:156-168. [PMID: 37498417 PMCID: PMC10693506 DOI: 10.1007/s10728-023-00464-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2023] [Indexed: 07/28/2023]
Abstract
Rising health insurance costs and the cost of living crisis are likely leading to an increase in unpaid health insurance bills in many countries. In Switzerland, a particularly drastic measure to sanction defaulting insurance payers is employed. Since 2012, Swiss cantons - who have to cover most of the bills of defaulting payers - are allowed by federal law to blacklist them and to restrict their access to medical care to emergencies.In our paper, we briefly describe blacklisting in the context of the Swiss healthcare system before we examine the ethical issues involved in light of what is known about its social and health impacts. We found no evidence that blacklisting serves as an effective way of recovering unpaid health insurance contributions or of strengthening solidarity within the health insurance system. Furthermore, the ambiguous definitions of what constitutes an emergency treatment and the incompatibility of the denial of medical care with the obligation to provide professional assistance complicate the implementation of blacklists and expose care providers to enormous pressure.Therefore, we conclude that blacklists and the (partial) denial of medical care not only pose profound ethical problems but are also unsuitable for fulfilling the purpose for which they were introduced.
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Affiliation(s)
- Hanna Glaus
- Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich, Winterthurerstrasse 30, Zürich, 8006, Switzerland
| | - Daniel Drewniak
- Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich, Winterthurerstrasse 30, Zürich, 8006, Switzerland
| | - Julian W März
- Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich, Winterthurerstrasse 30, Zürich, 8006, Switzerland
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich, Winterthurerstrasse 30, Zürich, 8006, Switzerland.
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Hajibonabi F, Taye M, Ubanwa A, Rowe JS, Sharperson C, Hanna TN, Johnson JO. Time ratio disparities among ED patients undergoing head CT. Emerg Radiol 2023; 30:453-463. [PMID: 37349643 DOI: 10.1007/s10140-023-02152-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/15/2023] [Indexed: 06/24/2023]
Abstract
PURPOSE To assess if patients who underwent head computed tomography (CT) experienced disparities in the emergency department (ED) and if the indication for head CT affected disparities. METHODS This study employed a retrospective, IRB-approved cohort design encompassing four hospitals. All ED patients between January 2016 and September 2020 who underwent non-contrast head CTs were included. Furthermore, key time intervals including ED length of stay (LOS), ED assessment time, image acquisition time, and image interpretation time were calculated. Time ratio (TR) was used to compare these time intervals between the groups. RESULTS A total of 45,177 ED visits comprising 4730 trauma cases, 5475 altered mental status cases, 11,925 cases with head pain, and 23,047 cases with other indications were included. Females had significantly longer ED LOS, ED assessment time, and image acquisition time (TR = 1.012, 1.051, 1.018, respectively, P-value < 0.05). This disparity was more pronounced in female patients with head pain complaints compared to their male counterparts (TR = 1.036, 1.059, and 1.047, respectively, P-value < 0.05). Black patients experienced significantly longer ED LOS, image acquisition time, and image assessment time (TR = 1.226, 1.349, and 1.190, respectively, P-value < 0.05). These disparities persisted regardless of head CT indications. Furthermore, patients with Medicare/Medicaid insurance also faced longer wait times in all the time intervals (TR > 1, P-value < 0.001). CONCLUSIONS Wait times for ED head CT completion were longer for Black patients and Medicaid/Medicare insurance holders. Additionally, females experienced extended wait times, particularly when presented with head pain complaints. Our findings underscore the importance of exploring and addressing the contributing factors to ensure equitable and timely access to imaging services in the ED.
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Affiliation(s)
- Farid Hajibonabi
- Department of Radiology and Imaging Sciences, Emory University, 1364 Clifton Road, Atlanta, GA, 30322, USA.
| | - Marta Taye
- Department of Radiology and Imaging Sciences, Emory University, 1364 Clifton Road, Atlanta, GA, 30322, USA
| | - Angela Ubanwa
- Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop Street Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Jean Sebastien Rowe
- Department of Radiology, Cooper University Hospital, 1 Cooper Plaza, Camden, NJ, 08103, USA
| | - Camara Sharperson
- Department of Radiology and Imaging Sciences, Emory University, 1364 Clifton Road, Atlanta, GA, 30322, USA
| | - Tarek N Hanna
- Department of Radiology and Imaging Sciences, Emory University, 1364 Clifton Road, Atlanta, GA, 30322, USA
| | - Jamlik-Omari Johnson
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, USA
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Chen P, Lazar A, Ding J, Siracuse JJ, Patel VI, Morrissey NJ. Insurance status is associated with urgent carotid endarterectomy and worse postoperative outcomes. J Vasc Surg 2023; 77:818-826.e1. [PMID: 36257345 PMCID: PMC9974840 DOI: 10.1016/j.jvs.2022.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Underinsured patients can experience worse preoperative medical optimization. We aimed to determine whether insurance status was associated with carotid endarterectomy (CEA) urgency and postoperative outcomes. METHODS We analyzed the Society for Vascular Surgery Vascular Quality Initiative Carotid Endarterectomy dataset from January 2012 to January 2021. Univariable and multivariable methods were used to analyze the differences across the insurance types for the primary outcome variable: CEA urgency. The analyses were limited to patients aged <65 years to minimize age confounding across insurers. We also examined differences in preoperative medical optimization and symptomatic disease and postoperative outcomes. A secondary analysis was performed to examine the effect of CEA urgency on the postoperative outcomes. RESULTS A total of 27,331 patients had undergone first-time CEA. Of these patients, 4600 (17%) had Medicare, 3440 (13%) had Medicaid, 17,917 (65%) had commercial insurance, and 1374 (5%) were uninsured. The Medicaid and uninsured patients had higher rates of urgent operation compared with Medicare (20.0% and 34.7% vs 14.4%; P < .001), with no differences in the commercial group vs the Medicare group. Additionally, Medicaid and uninsured patients had lower rates of aspirin, statin, and/or antiplatelet use (93.6% and 93.5% vs 95.8%; P < .001) and higher rates of symptomatic disease (42.1% and 57.6% vs 36.2%; P < .001) compared with Medicare patients. The rate of perioperative stroke/death was higher for the Medicaid and uninsured patients than for the Medicare patients (1.63% and 1.89% vs 1.02%; P = .017 and P = .01, respectively), with no differences in the commercial group. Multivariable analysis demonstrated that compared with Medicare, Medicaid and uninsured status were associated with increased odds of an urgent operation (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.5; and OR, 2.3; 95% CI, 2.0-2.7, respectively), symptomatic disease (OR, 1.2; 95% CI, 1.1-1.4; and OR, 2.2; 95% CI, 1.9-2.5, respectively), and perioperative stroke/death (OR, 1.6; 95% CI, 1.1-2.4; and OR, 1.8; 95% CI, 1.1-3.0, respectively) and a decreased odds of aspirin, statin, and/or antiplatelet use (OR, 0.71; 95% CI, 0.6-0.9; and OR, 0.76; 95% CI, 0.6-0.99, respectively). Additionally, the rates of perioperative stroke/death were higher for patients who had required urgent surgery compared with elective surgery (2.8% vs 1.0%; P < .001). Multivariable analysis demonstrated increased odds of perioperative stroke/death for patients who had required urgent surgery (OR, 2.4; 95% CI, 1.9-3.1). CONCLUSIONS Medicaid and uninsured patients were more likely to require urgent CEA, in part because of poor preoperative medical optimization. Additionally, urgent operation was independently associated with worse postoperative outcomes. These results highlight the need for improved preoperative follow-up for underinsured populations.
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Affiliation(s)
- Panpan Chen
- Division of Cardiac, Thoracic, and Vascular Surgery, NewYork-Presbyterian Columbia University Irving Medical Center, New York, NY
| | - Andrew Lazar
- Division of Cardiac, Thoracic, and Vascular Surgery, NewYork-Presbyterian Columbia University Irving Medical Center, New York, NY
| | - Jessica Ding
- Division of Cardiac, Thoracic, and Vascular Surgery, NewYork-Presbyterian Columbia University Irving Medical Center, New York, NY
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, NewYork-Presbyterian Columbia University Irving Medical Center, New York, NY
| | - Nicholas J Morrissey
- Division of Cardiac, Thoracic, and Vascular Surgery, NewYork-Presbyterian Columbia University Irving Medical Center, New York, NY.
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8
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Knighton AJ, Wolfe D, Hunt A, Neeley A, Shrestha N, Hess S, Hellewell J, Snow G, Srivastava R, Nelson D, Schunk JE. Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study. Ann Emerg Med 2022; 80:332-343. [PMID: 35752519 PMCID: PMC9509420 DOI: 10.1016/j.annemergmed.2022.04.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 04/13/2022] [Accepted: 04/22/2022] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE To measure the effectiveness of a multimodal strategy, including simultaneous implementation of a clinical decision support system, to sustain adherence to a clinical pathway for care of children with minor head trauma treated in general emergency departments (EDs). METHODS Prospective, type III hybrid effectiveness-implementation cohort study with a nonrandomized stepped-wedge design and monthly repeated site measures. The study population included pediatric minor head trauma encounters from July 2018 to December 2020 at 21 urban and rural general ED sites in an integrated health care system. Sites received the intervention in 1 of 2 steps, with each site providing control and intervention observations. Measures included guideline adherence, the computed tomography (CT) scan rate, and 72-hour readmissions with clinically important traumatic brain injury. Analysis was performed using multilevel hierarchical modeling with random intercepts for the site and physician. RESULTS During the study, 12,670 pediatric minor head trauma encounters were cared for by 339 clinicians. The implementation of the clinical pathway resulted in higher odds of guideline adherence (adjusted odds ratio 1.12 [95% confidence interval 1.03 to 1.22]) and lower odds of a CT scan (adjusted odds ratio 0.96 [95% confidence interval 0.93 to 0.98]) in intervention versus control months. Absolute risk difference was observed in both guideline adherence (site median: +2.3% improvement) and the CT scan rate (site median: -6.6% reduction). No 72-hour readmissions with confirmed clinically important traumatic brain injury were identified. CONCLUSION Implementation of a minor head trauma clinical pathway using a multimodal approach, including a clinical decision support system, led to sustained improvements in adherence and a modest, yet safe, reduction in CT scans among generally low-risk patients in diverse general EDs.
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Affiliation(s)
| | - Doug Wolfe
- Intermountain Healthcare, Salt Lake City, UT
| | | | | | | | - Steven Hess
- Intermountain Healthcare, Salt Lake City, UT
| | | | | | - Rajendu Srivastava
- Intermountain Healthcare, Salt Lake City, UT; University of Utah School of Medicine, Salt Lake City, UT
| | - Douglas Nelson
- Intermountain Healthcare, Salt Lake City, UT; University of Utah School of Medicine, Salt Lake City, UT
| | - Jeff E Schunk
- University of Utah School of Medicine, Salt Lake City, UT
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Calvillo AÁG, Kodaverdian LC, Garcia R, Lichtensztajn DY, Bucknor MD. Patient-level factors influencing adherence to follow-up imaging recommendations. Clin Imaging 2022; 90:5-10. [PMID: 35907273 DOI: 10.1016/j.clinimag.2022.07.006] [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: 04/29/2022] [Revised: 07/09/2022] [Accepted: 07/18/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To determine which, if any, patient-level factors were associated with differences in completion of follow-up imaging recommendations at a tertiary academic medical center. METHODS In this IRB-approved, retrospective cohort study, approximately one month of imaging recommendations were reviewed from 2017 at a single academic institution that contained key words recommending follow-up imaging. Age, gender, race/ethnicity, insurance, smoking history, primary language, BMI, and home address were recorded via chart extraction. Home addresses were geocoded to Census Block Groups and assigned to a quintile of neighborhood socioeconomic status. A multivariate logistic regression model was used to evaluate each predictor variable with significance set to p = 0.05. RESULTS A total of 13,421 imaging reports that included additional follow-up recommendations were identified. Of the 1013 included reports that recommended follow-up, 350 recommended additional imaging and were analyzed. Three hundred eight (88.00%) had corresponding follow-up imaging present and the insurance payor was known for 266 (86.36%) patients: 146 (47.40%) had commercial insurance, 35 (11.36%) had Medicaid, and 85 (27.60%) had Medicare. Patients with Medicaid had over four times lower odds of completing follow-up imaging compared to patients with commercial insurance (OR 0.24, 95% CI 0.06-0.88, p = 0.032). Age, gender, race/ethnicity, smoking history, primary language, BMI, and neighborhood socioeconomic status were not independently associated with differences in follow-up imaging completion. CONCLUSION Patients with Medicaid had decreased odds of completing follow-up imaging recommendations compared to patients with commercial insurance.
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Affiliation(s)
- Andrés Ángel-González Calvillo
- University of California San Francisco School of Medicine, 513 Parnassus Ave., Suite S-245, San Francisco, CA 94143, USA.
| | | | - Roxana Garcia
- University of California San Francisco School of Medicine, 513 Parnassus Ave., Suite S-245, San Francisco, CA 94143, USA.
| | - Daphne Y Lichtensztajn
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St., 2nd floor, San Francisco, CA 94158, USA.
| | - Matthew D Bucknor
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry St., Suite 350, Lobby 6, San Francisco, CA 94107, USA.
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Li J, Ramgopal S, Marin JR. Racial and ethnic differences in low-value pediatric emergency care. Acad Emerg Med 2022; 29:698-709. [PMID: 35212440 DOI: 10.1111/acem.14468] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/28/2021] [Accepted: 01/06/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Disparities in health care quality frequently focus on underuse. We evaluated racial/ethnic differences in low-value services delivered in the pediatric emergency department (ED). METHODS We performed a retrospective cross-sectional study of low-value services in children discharged from 39 pediatric EDs from January 2018 to December 2019 using the Pediatric Hospital Information System. Our primary outcome was receipt of one of 12 low-value services across nine conditions, including chest radiography in asthma and bronchiolitis; beta-agonist and corticosteroids in bronchiolitis; laboratory testing and neuroimaging in febrile seizure; neuroimaging in afebrile seizure; head injury and headache; and any imaging in sinusitis, constipation, and facial trauma. We analyzed the association of race/ethnicity on receipt of low-value services using generalized linear mixed models adjusted for age, sex, weekend, hour of presentation, payment, year, household income, and distance from hospital. RESULTS We included 4,676,802 patients. Compared with non-Hispanic White (NHW) patients, non-Hispanic Black (NHB) and Hispanic patients had lower adjusted odds (aOR [95% confidence interval]) of receiving imaging for asthma (0.60 [0.56 to 0.63] NHB; 0.84 [0.79 to 0.89] Hispanic), bronchiolitis (0.84 [0.79 to 0.89] NHB; 0.93 [0.88 to 0.99] Hispanic), head injury (0.84 [0.80 to 0.88] NHB; 0.80 [0.76 to 0.84] Hispanic), headache (0.67 [0.63 to 0.72] NHB; 0.83 [0.78 to 0.88] Hispanic), and constipation (0.71 [0.67 to 0.74] NHB; 0.76 [0.72 to 0.80] Hispanic). NHB patients had lower odds (95% CI) of receiving imaging for afebrile seizures (0.89 [0.8 to 1.0]) and facial trauma (0.69 [0.60 to 0.80]). Hispanic patients had lower odds (95% CI) of imaging (0.57 [0.36 to 0.90]) and blood testing (0.82 [0.69 to 0.98]) for febrile seizures. NHB patients had higher odds (95% CI) of receiving steroids (1.11 [1.00 to 1.21]) and beta-agonists (1.38 [1.24 to 1.54]) for bronchiolitis compared with NHW patients. CONCLUSIONS NHW patients more frequently receive low-value imaging while NHB patients more frequently receive low-value medications for bronchiolitis. Our study demonstrates the differences in care across race and ethnicity extend to many services, including those of low value. These findings highlight the importance of greater understanding of the complex interaction of race and ethnicity with clinical practice.
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Affiliation(s)
- Joyce Li
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School Boston Massachusetts USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Jennifer R. Marin
- Division of Pediatric Emergency Medicine UPMC Children's Hospital of Pittsburgh University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
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11
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DeBenedectis CM, Spalluto LB, Americo L, Bishop C, Mian A, Sarkany D, Kagetsu NJ, Slanetz PJ. Health Care Disparities in Radiology-A Review of the Current Literature. J Am Coll Radiol 2022; 19:101-111. [PMID: 35033297 DOI: 10.1016/j.jacr.2021.08.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/31/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Health care disparities exist in all medical specialties, including radiology. Raising awareness of established health care disparities is a critical component of radiology's efforts to mitigate disparities. Our primary objective is to perform a comprehensive review of the last 10 years of literature pertaining to disparities in radiology care. Our secondary objective is to raise awareness of disparities in radiology. METHODS We reviewed English-language medicine and health services literature from the past 10 years (2010-2020) for research that described disparities in any aspect of radiologic imaging using radiology search terms and key words for disparities in OVID. Relevant studies were identified with adherence to the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS The search yielded a total 1,890 articles. We reviewed the citations and abstracts with the initial search yielding 1,890 articles (without duplicates). Of these, 1,776 were excluded based on the criteria set forth in the methods. The remaining unique 114 articles were included for qualitative synthesis. DISCUSSION We hope this article increases awareness and inspires action to address disparities and encourages research that further investigates previously identified disparities and explores not-yet-identified disparities.
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Affiliation(s)
- Carolynn M DeBenedectis
- Vice-Chair, Education; Director, Radiology Residency Program; Department of Radiology, President-elect, New England Roentgen Ray Society; and Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts.
| | - Lucy B Spalluto
- Vice-Chair, Health Equity; Director, Women in Radiology; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Ingram Cancer Center, Nashville, Tennessee; Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research; and Education and Clinical Center (GRECC), Nashville, Tennessee
| | - Lisa Americo
- Department of Radiology, Staten Island University Hospital Northwell Health, Staten Island, New York
| | - Casey Bishop
- Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - Asim Mian
- Director, Radiology Residency Program; Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - David Sarkany
- Director, Radiology Residency Program; Department of Radiology, Staten Island University Hospital Northwell Health, Staten Island, New York
| | - Nolan J Kagetsu
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Priscilla J Slanetz
- Vice-Chair, Academic Affairs; Associate Program Director, Radiology Residency Program, Boston Medical Center; President-elect Massachusetts Radiologic Society; Secretary, Association of University Radiologists; Chair, Breast Imaging Panel 2, ACR Appropriateness Guidelines Committee; and Department of Radiology, Boston Medical Center, Boston, Massachusetts
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12
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Abraham P, Bishay AE, Farah I, Williams E, Tamayo-Murillo D, Newton IG. Reducing Health Disparities in Radiology Through Social Determinants of Health: Lessons From the COVID-19 Pandemic. Acad Radiol 2021; 28:903-910. [PMID: 34001438 DOI: 10.1016/j.acra.2021.04.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/13/2021] [Accepted: 04/22/2021] [Indexed: 12/20/2022]
Abstract
During the COVID-19 pandemic, the disproportionate morbidity and mortality borne by racial minorities, patients of lower socioeconomic status, and patients lacking health insurance reflect the critical role of social determinants of health, which are manifestations of entrenched structural inequities. In radiology, social determinants of health lead to disparate use of imaging services through multiple intersecting contributors, on both the provider and patient side, affecting diagnosis and treatment. Disparities on the provider side include ordering of initial or follow-up imaging studies and providing standard-of-care interventional procedures, while patient factors include differences in awareness of screening exams and confidence in the healthcare system. Disparate utilization of mammography and lung cancer screening lead to delayed diagnosis, while differential provision of minimally invasive interventional procedures contributes to differential outcomes related to treatment. Interventions designed to mitigate social determinants of health could help to equalize the healthcare system. Here we review disparities in access and health outcomes in radiology. We investigate underlying contributing factors in order to identify potential policy changes that could promote more equitable health in radiology.
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Abstract
OBJECTIVE. This article aimed to assess changing use of brain imaging tests among patients with Alzheimer disease and vascular dementia who visited U.S. emergency departments (EDs) between 2006 and 2014. MATERIALS AND METHODS. Using the largest publicly available all-payer ED database, the Nationwide Emergency Department Sample, we identified a weighted cohort of 427,705 individuals with Alzheimer disease and 33,743 individuals with vascular dementia who visited U.S. EDs between 2006 and 2014. Logistic regression analyses were performed to identify factors associated with use. RESULTS. Between 2006 and 2014, ED visits among patients with Alzheimer disease and vascular dementia declined by 24.7% and 20.3%, respectively. However, there was a significant increase in utilization rates of head CT (from 4.4% to 11.1% in patients with Alzheimer disease and from 1.5% to 2.9% in patients with vascular dementia) and brain MRI (from 0.04% to 0.5% in patients with Alzheimer disease and 0.0% to 0.1% in those with vascular dementia) in the same time period. Among patients with Alzheimer disease, age, median income in patient ZIP code, day of the week of the ED visit, hospital teaching status, and hospital geographic region were significant predictors of imaging use. Among patients with vascular dementia, insurance type and hospital classification (urban vs rural) were significant predictors of imaging use. CONCLUSION. Despite declining ED visits, ED brain imaging in patients with Alzheimer disease and vascular dementia has increased. Various patient-specific and hospital-specific factors contribute to differential utilization rates.
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Marin JR, Rodean J, Hall M, Alpern ER, Aronson PL, Chaudhari PP, Cohen E, Freedman SB, Morse RB, Peltz A, Samuels-Kalow M, Shah SS, Simon HK, Neuman MI. Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children's Hospitals, 2016-2019. JAMA Netw Open 2021; 4:e2033710. [PMID: 33512517 PMCID: PMC7846940 DOI: 10.1001/jamanetworkopen.2020.33710] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Diagnostic imaging is frequently performed as part of the emergency department (ED) evaluation of children. Whether imaging patterns differ by race and ethnicity is unknown. OBJECTIVE To evaluate racial and ethnic differences in the performance of common ED imaging studies and to examine patterns across diagnoses. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study evaluated visits by patients younger than 18 years to 44 US children's hospital EDs from January 1, 2016, through December 31, 2019. EXPOSURES Non-Hispanic Black and Hispanic compared with non-Hispanic White race/ethnicity. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of visits for each race/ethnicity group with at least 1 diagnostic imaging study, defined as plain radiography, computed tomography, ultrasonography, and magnetic resonance imaging. The major diagnostic categories classification system was used to examine race/ethnicity differences in imaging rates by diagnoses. RESULTS A total of 13 087 522 visits by 6 230 911 children and adolescents (mean [SD] age, 5.8 [5.2] years; 52.7% male) occurred during the study period. Diagnostic imaging was performed during 3 689 163 visits (28.2%). Imaging was performed in 33.5% of visits by non-Hispanic White patients compared with 24.1% of visits by non-Hispanic Black patients (odds ratio [OR], 0.60; 95% CI, 0.60-0.60) and 26.1% of visits by Hispanic patients (OR, 0.66; 95% CI, 0.66-0.67). Adjusting for confounders, visits by non-Hispanic Black (adjusted OR, 0.82; 95% CI, 0.82-0.83) and Hispanic (adjusted OR, 0.87; 95% CI, 0.87-0.87) patients were less likely to include any imaging study compared with visits by non-Hispanic White patients. Limiting the analysis to only visits by nonhospitalized patients, the adjusted OR for imaging was 0.79 (95% CI, 0.79-0.80) for visits by non-Hispanic Black patients and 0.84 (95% CI, 0.84-0.85) for visits by Hispanic patients. Results were consistent in analyses stratified by public and private insurance groups and did not materially differ by diagnostic category. CONCLUSIONS AND RELEVANCE In this study, non-Hispanic Black and Hispanic children were less likely to receive diagnostic imaging during ED visits compared with non-Hispanic White children. Further investigation is needed to understand and mitigate these potential disparities in health care delivery and to evaluate the effect of these differential imaging patterns on patient outcomes.
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Affiliation(s)
- Jennifer R. Marin
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rustin B. Morse
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Harold K. Simon
- Division of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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15
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Patient Race/Ethnicity and Diagnostic Imaging Utilization in the Emergency Department: A Systematic Review. J Am Coll Radiol 2020; 18:795-808. [PMID: 33385337 DOI: 10.1016/j.jacr.2020.12.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE Diagnostic imaging often is a critical contributor to clinical decision making in the emergency department (ED). Racial and ethnic disparities are widely reported in many aspects of health care, and several recent studies have reported a link between patient race/ethnicity and receipt of imaging in the ED. METHODS The authors conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching three databases (PubMed, Embase, and the Cochrane Library) through July 2020 using keywords related to diagnostic imaging, race/ethnicity, and the ED setting, including both adult and pediatric populations and excluding studies that did not control for the important confounders of disease severity and insurance status. RESULTS The search strategy identified 7,313 articles, of which 5,668 underwent title and abstract screening and 238 full-text review, leaving 42 articles meeting the inclusion criteria. Studies were predominately conducted in the United States (41), split between adult (13) and pediatric (17) populations or both (12), and spread across a variety of topics, mostly focusing on specific anatomic regions or disease processes. Most studies (30 of 42 [71.4%]) reported an association between Black, African American, Hispanic, or nonwhite race/ethnicity and decreased receipt of imaging. CONCLUSIONS Despite heterogeneity among studies, patient race/ethnicity is linked with receipt of diagnostic imaging in the ED. The strength and directionality of this association may differ by specific subpopulation and disease process, and more efforts to understand potential underlying factors are needed.
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Trofimova AV, Duszak R, Kadom N, Sadigh G. Increasing and disparate use of neuroimaging for adults and children with non-traumatic headaches in the US emergency departments: Opportunities for improvement. Headache 2020; 61:179-189. [PMID: 33316103 DOI: 10.1111/head.14020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/01/2020] [Accepted: 09/06/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Optimization of neuroimaging practices for headache is considered a national priority; however, nationwide patterns and predictors of neuroimaging use for headache in the US emergency departments (EDs) are unknown. OBJECTIVE To analyze temporal neuroimaging utilization trends for adults and children with non-traumatic headache in the US EDs and identify factors predictive of neuroimaging use in this patient population. METHODS Retrospective cross-sectional study using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database for administrative encounter-level data analysis of a nationwide group of adult and pediatric patients with primary diagnosis of headache (ICD-9CM codes 784.0x, 339.xx, 346.xx) visited the US EDs between January 1, 2006 and December 31, 2014. Temporal trends and independent predictors of neuroimaging use (e.g., patient and hospital characteristics, primary payment sources) were determined. RESULTS In 2006-2014, a weighted group of 18,146,302 patients with a primary diagnosis of non-traumatic headache visited US EDs. Advanced neuroimaging utilization increased from 18.6% (n = 350,777) to 34.8% (n = 756,895) in the total group, from 18.8% (n = 314,646) to 36.5% (n = 698,080) in the adult subgroup (+94.1%), and from 16.9% (n = 36,131) to 22.0% (n = 58,815) (+30.2%) in the pediatric subgroup (+87.0%) between 2006 and 2014. The strongest predictors of higher neuroimaging utilization were hospital location in the Northeast (OR 3.17, 95% CI 2.67-3.76) or South (OR 2.42, 95% CI 2.03-2.88) regions. Lower utilization of imaging was associated with weekend ED visits (OR 0.92, 95% CI 0.92-0.93), female gender (OR 0.82, 95% CI 0.81-0.83), and Medicare, Medicaid, or self-pay (vs. private insurance) encounters. CONCLUSION Neuroimaging utilization in patients with headache in US EDs nearly doubled in 2006-2014, and was used in 34.8% of all ED encounters in 2014. Utilization was higher and increased at faster rates for adults than children. In US EDs, imaging for headache is preferentially performed on commercially insured and male patients, at urban hospitals, in certain geographic regions, and on weekdays, raising concerns regarding disparate imaging use.
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Affiliation(s)
- Anna V Trofimova
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Gelareh Sadigh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
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Balthazar P, Sadigh G, Hughes D, Rosenkrantz AB, Hanna T, Duszak R. Increasing Use, Geographic Variation, and Disparities in Emergency Department CT for Suspected Urolithiasis. J Am Coll Radiol 2019; 16:1547-1553. [DOI: 10.1016/j.jacr.2019.05.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/14/2019] [Accepted: 05/18/2019] [Indexed: 01/06/2023]
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Quality Improvement and Reimbursements: An Opportunity to Address Health Disparities in Radiology. J Am Coll Radiol 2019; 16:635-637. [DOI: 10.1016/j.jacr.2018.12.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 12/19/2018] [Indexed: 01/03/2023]
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Wang KY, Malayil Lincoln CM, Chen MM. Radiology Support, Communication, and Alignment Network and Its Role to Promote Health Equity in the Delivery of Radiology Care. J Am Coll Radiol 2019; 16:638-643. [DOI: 10.1016/j.jacr.2018.12.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 12/22/2018] [Indexed: 12/14/2022]
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20
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Failure to rescue and disparities in emergency general surgery. J Surg Res 2018; 231:62-68. [DOI: 10.1016/j.jss.2018.04.047] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 03/13/2018] [Accepted: 04/18/2018] [Indexed: 11/22/2022]
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Impact of Delayed Time to Advanced Imaging on Missed Appointments Across Different Demographic and Socioeconomic Factors. J Am Coll Radiol 2018; 15:713-720. [PMID: 29503152 DOI: 10.1016/j.jacr.2018.01.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/11/2018] [Accepted: 01/21/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE The aim of this study was to investigate the impact of wait days (WDs) on missed outpatient MRI appointments across different demographic and socioeconomic factors. METHODS An institutional review board-approved retrospective study was conducted among adult patients scheduled for outpatient MRI during a 12-month period. Scheduling data and demographic information were obtained. Imaging missed appointments were defined as missed scheduled imaging encounters. WDs were defined as the number of days from study order to appointment. Multivariate logistic regression was applied to assess the contribution of race and socioeconomic factors to missed appointments. Linear regression was performed to assess the relationship between missed appointment rates and WDs stratified by race, income, and patient insurance groups with analysis of covariance statistics. RESULTS A total of 42,727 patients met the inclusion criteria. Mean WDs were 7.95 days. Multivariate regression showed increased odds ratio for missed appointments for patients with increased WDs (7-21 days: odds ratio [OR], 1.39; >21 days: OR, 1.77), African American patients (OR, 1.71), Hispanic patients (OR, 1.30), patients with noncommercial insurance (OR, 2.00-2.55), and those with imaging performed at the main hospital campus (OR, 1.51). Missed appointment rate linearly increased with WDs, with analysis of covariance revealing underrepresented minorities and Medicaid insurance as significant effect modifiers. CONCLUSIONS Increased WDs for advanced imaging significantly increases the likelihood of missed appointments. This effect is most pronounced among underrepresented minorities and patients with lower socioeconomic status. Efforts to reduce WDs may improve equity in access to and utilization of advanced diagnostic imaging for all patients.
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22
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Glover M, Daye D, Khalilzadeh O, Pianykh O, Rosenthal DI, Brink JA, Flores EJ. Socioeconomic and Demographic Predictors of Missed Opportunities to Provide Advanced Imaging Services. J Am Coll Radiol 2017; 14:1403-1411. [DOI: 10.1016/j.jacr.2017.05.015] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 05/25/2017] [Accepted: 05/26/2017] [Indexed: 01/02/2023]
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Karvelas DA, Rundell SD, Friedly JL, Gellhorn AC, Gold LS, Comstock BA, Heagerty PJ, Bresnahan BW, Nerenz DR, Jarvik JG. Subsequent health-care utilization associated with early physical therapy for new episodes of low back pain in older adults. Spine J 2017; 17:380-389. [PMID: 27765707 DOI: 10.1016/j.spinee.2016.10.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 08/29/2016] [Accepted: 10/12/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND The association between early physical therapy (PT) and subsequent health-care utilization following a new visit for low back pain is not clear, particularly in the setting of acute low back pain. PURPOSE This study aimed to estimate the association between initiating early PT following a new visit for an episode of low back pain and subsequent back pain-specific health-care utilization in older adults. DESIGN/SETTING This is a prospective cohort study. Data were collected at three integrated health-care systems in the United States through the Back Pain Outcomes using Longitudinal Data (BOLD) registry. PATIENT SAMPLE We recruited 4,723 adults, aged 65 and older, presenting to a primary care setting with a new episode of low back pain. OUTCOME MEASURES Primary outcome was total back pain-specific relative value units (RVUs), from days 29 to 365. Secondary outcomes included overall RVUs for all health care and use of specific health-care services including imaging (x-ray and magnetic resonance imaging [MRI] or computed tomography [CT]), emergency department visits, physician visits, PT, spinal injections, spinal surgeries, and opioid use. METHODS We compared patients who had early PT (initiated within 28 days of the index visit) with those not initiating early PT using appropriate, generalized linear models to adjust for potential confounding variables. RESULTS Adjusted analysis found no statistically significant difference in total spine RVUs between the two groups (ratio of means 1.19, 95% CI of 0.72-1.96, p=.49). For secondary outcomes, only the difference between total spine imaging RVUs and total PT RVUs was statistically significant. The early PT group had greater PT RVUs; the ratio of means was 2.56 (95% CI of 2.17-3.03, p<.001). The early PT group had greater imaging RVUs; the ratio of means was 1.37 (95% CI of 1.09-1.71, p=.01.) CONCLUSIONS: We found that in a group of older adults presenting for a new episode of low back pain, the use of early PT is not associated with any statistically significant difference in subsequent back pain-specific health-care utilization compared with patients not receiving early PT.
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Affiliation(s)
- Deven A Karvelas
- Rebound Orthopedics and Neurosurgery 200 NE Mother Joseph Place Suite 210 Vancouver, WA, 98664.
| | - Sean D Rundell
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave. NE Box 359455, 14th Floor Seattle, WA 98105
| | - Janna L Friedly
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave. NE Box 359455, 14th Floor Seattle, WA 98105
| | - Alfred C Gellhorn
- Department of Rehabilitation and Regenerative Medicine, Weill Cornell Medical Center, 525 East 68th St., 16th Floor New York, NY 10065
| | - Laura S Gold
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave. NE Box 359455, 14th Floor Seattle, WA 98105
| | - Bryan A Comstock
- Center for Biomedical Statistics, University of Washington, Box 357232 Seattle, WA 98195
| | - Patrick J Heagerty
- Center for Biomedical Statistics, University of Washington, Box 357232 Seattle, WA 98195
| | - Brian W Bresnahan
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave. NE Box 359455, 14th Floor Seattle, WA 98105
| | - David R Nerenz
- Neuroscience Institute, Henry Ford Hospital, 2799 West Grand Blvd Detroit, MI 48202
| | - Jeffrey G Jarvik
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave. NE Box 359455, 14th Floor Seattle, WA 98105
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Gold LS, Bryan M, Comstock BA, Bresnahan BW, Deyo RA, Nedeljkovic SS, Nerenz DR, Heagerty P, Jarvik JG. Associations Between Relative Value Units and Patient-Reported Back Pain and Disability. Gerontol Geriatr Med 2017; 3:2333721416686019. [PMID: 28405596 PMCID: PMC5384601 DOI: 10.1177/2333721416686019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 11/23/2016] [Accepted: 11/28/2016] [Indexed: 11/27/2022] Open
Abstract
Objective: To describe associations between health care utilization measures and patient-reported outcomes (PROs). Method: Primary data were collected from patients ≥65 years with low back pain visits from 2011 to 2013. Six PROs of pain and functionality were collected 12 and 24 months after the index visits and total and spine-specific relative value units (RVUs) from electronic health records were tabulated over 1 year. We calculated correlation coefficients between RVUs and 12- and 24-month PROs and conducted linear regressions with each 12- and 24-month PRO as the outcome variables and RVUs as predictors of interest. Results: We observed very weak correlations between worse PROs at 12 and 24 months and greater 12-month utilization. In regression analyses, we observed slight associations between greater utilization and worse 12- and 24-month PROs. Discussion: We found that 12-month health care utilization is not strongly associated with PROs at 12 or 24 months.
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Affiliation(s)
| | | | | | | | | | - Srdjan S. Nedeljkovic
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Vanguard Medical Associates, Chestnut Hill, MA, USA
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Derakhshan A, Miller J, Lubelski D, Nowacki AS, Wells BJ, Milinovich A, Benzel EC, Mroz TE, Steinmetz MP. The Impact of Socioeconomic Status on the Utilization of Spinal Imaging. Neurosurgery 2016. [PMID: 26214318 DOI: 10.1227/neu.0000000000000914] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Few studies have examined the general correlation between socioeconomic status and imaging. This study is the first to analyze this relationship in the spine patient population. OBJECTIVE To assess the effect of socioeconomic status on the frequency with which imaging studies of the lumbar spine are ordered and completed. METHODS Patients that were diagnosed with lumbar radiculopathy and/or myelopathy and had at least 1 subsequent lumbar magnetic resonance imaging (MRI), computed tomography (CT), or X-ray ordered were retrospectively identified. Demographic information and the number of ordered and completed imaging studies were among the data collected. Patient insurance status and income level (estimated based on zip code) served as representations of socioeconomic status. RESULTS A total of 24,105 patients met the inclusion criteria for this study. Regression analyses demonstrated that uninsured patients were significantly less likely to have an MRI, CT, or X-ray study ordered (P < .001 for all modalities) and completed (P < .001 for MRI and X-ray, P = .03 for CT). Patients with lower income had higher rates of MRI, CT, and X-ray (P < .001 for all) imaging ordered but were less likely to have an ordered X-ray be completed (P = .009). There was no significant difference in the completion rate of ordered MRIs or CTs. CONCLUSION Disparities in image utilization based on socioeconomic characteristics such as insurance status and income level highlight a critical gap in access to health care. Physicians should work to mitigate the influence of such factors when deciding whether to order imaging studies, especially in light of the ongoing shift in health policy in the United States.
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Affiliation(s)
- Adeeb Derakhshan
- *Cleveland Clinic Lerner College of Medicine, Cleveland Clinic Center for Spine Health, and Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio; ‡Cleveland Clinic Department of Quantitative Health Sciences, Cleveland, Ohio
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26
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Kanzaria HK, McCabe AM, Meisel ZM, LeBlanc A, Schaffer JT, Bellolio MF, Vaughan W, Merck LH, Applegate KE, Hollander JE, Grudzen CR, Mills AM, Carpenter CR, Hess EP. Advancing Patient-centered Outcomes in Emergency Diagnostic Imaging: A Research Agenda. Acad Emerg Med 2015; 22:1435-46. [PMID: 26574729 DOI: 10.1111/acem.12832] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 07/13/2015] [Indexed: 01/01/2023]
Abstract
Diagnostic imaging is integral to the evaluation of many emergency department (ED) patients. However, relatively little effort has been devoted to patient-centered outcomes research (PCOR) in emergency diagnostic imaging. This article provides background on this topic and the conclusions of the 2015 Academic Emergency Medicine consensus conference PCOR work group regarding "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The goal was to determine a prioritized research agenda to establish which outcomes related to emergency diagnostic imaging are most important to patients, caregivers, and other key stakeholders and which methods will most optimally engage patients in the decision to undergo imaging. Case vignettes are used to emphasize these concepts as they relate to a patient's decision to seek care at an ED and the care received there. The authors discuss applicable research methods and approaches such as shared decision-making that could facilitate better integration of patient-centered outcomes and patient-reported outcomes into decisions regarding emergency diagnostic imaging. Finally, based on a modified Delphi process involving members of the PCOR work group, prioritized research questions are proposed to advance the science of patient-centered outcomes in ED diagnostic imaging.
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Affiliation(s)
- Hemal K. Kanzaria
- Department of Emergency Medicine; University of California San Francisco & San Francisco General Hospital; San Francisco CA
- Robert Wood Johnson Clinical Scholars Program and the U.S. Department of Veterans Affairs; Los Angeles CA
- RAND Health; Santa Monica CA
| | - Aileen M. McCabe
- Department of Emergency Medicine; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
- Emergency Care Research Unit; Division of Population Health Sciences; Royal College of Surgeons in Ireland; Dublin Ireland
| | - Zachary M. Meisel
- Department of Emergency Medicine; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
- Center for Emergency Care Policy & Research; Perelman School of Medicine, and the Leonard Davis Institute of Health Economics; University of Pennsylvania; Philadelphia PA
| | - Annie LeBlanc
- Division of Health Care Policy and Research; Department of Health Sciences Research; Knowledge and Evaluation Research Unit; Mayo Clinic; Rochester MN
| | - Jason T. Schaffer
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - M. Fernanda Bellolio
- Department of Emergency Medicine; Mayo Clinic; Rochester MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery; Mayo Clinic; Rochester MN
| | | | - Lisa H. Merck
- Department of Emergency Medicine; The Warren Alpert Medical School of Brown University; Providence RI
- Department of Diagnostic Imaging; The Warren Alpert Medical School of Brown University; Providence RI
| | - Kimberly E. Applegate
- Department of Radiology and Imaging Sciences; Emory University School of Medicine; Atlanta GA
| | - Judd E. Hollander
- Department of Emergency Medicine; Sidney Kimmel Medical College of Thomas Jefferson University; Philadelphia PA
- National Academic Center for Telehealth; Philadelphia PA
| | - Corita R. Grudzen
- Department of Emergency Medicine; New York University; New York NY
- Department Population Health; New York University; New York NY
| | - Angela M. Mills
- Emergency Care Research Unit; Division of Population Health Sciences; Royal College of Surgeons in Ireland; Dublin Ireland
| | - Christopher R. Carpenter
- Division of Emergency Medicine; Washington University School of Medicine, and the Washington University Emergency Care Research Core; St. Louis MO
| | - Erik P. Hess
- Department of Emergency Medicine; Mayo Clinic; Rochester MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery; Mayo Clinic; Rochester MN
- Knowledge and Evaluation Research Unit; Division of Healthcare Policy Research; Department of Health Sciences Research; Mayo Clinic; Rochester MN
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Sevush-Garcy J, Gutierrez J. An Epidemiological Perspective on Race/Ethnicity and Stroke. CURRENT CARDIOVASCULAR RISK REPORTS 2015. [DOI: 10.1007/s12170-015-0448-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Duszak R, Nsiah E, Hughes DR, Maze J. Emergency department imaging: uncompensated services rendered by radiologists nationwide. J Am Coll Radiol 2015; 11:559-65. [PMID: 24899211 DOI: 10.1016/j.jacr.2013.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/05/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of this study was to examine characteristics of uncompensated services rendered by radiologists to emergency department (ED) patients. METHODS Using deidentified billing claims for 2,935 radiologists from 40 states from 2009 through 2012, 18,475,491 services rendered to ED patients were identified. Analysis focused on the 133 of 830 procedure codes that comprised 99.0% (18,296,734) of all rendered services. The frequency, magnitude, and other characteristics of uncompensated (defined as zero payment) radiologist services were analyzed. National 2012 Medicare Physician Fee Schedule amounts were used to estimate service dollar values. RESULTS Of 2,935 radiologists, 2,835 (96.6%) provided uncompensated care to ED patients, averaging $2,584 in professional services per physician per service month. Radiologists received no compensation at all for 28.4% of services (5,194,732 of 18,296,734). Just 8 procedure codes describing various chest, foot, and ankle radiographic and brain, abdominal and pelvic, and cervical spine CT examinations accounted for 51.0% of all imaging services rendered to ED patients. CT represented 31.2% of all services but accounted for 64.8% of uncompensated dollars. Although the uninsured received only 15.8% of all services, they accounted for 52.3% of all uncompensated services (2,714,506). CONCLUSION More than 28% of services rendered by radiologists to ED patients are uncompensated, corresponding to $2,584 per month per physician. That frequency and magnitude could have patient access implications.
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Affiliation(s)
- Richard Duszak
- Harvey L. Neiman Health Policy Institute, Reston, Virginia; Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.
| | - Eugene Nsiah
- Harvey L. Neiman Health Policy Institute, Reston, Virginia
| | - Danny R Hughes
- Harvey L. Neiman Health Policy Institute, Reston, Virginia
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Brinjikji W, El-Sayed AM, Kallmes DF, Lanzino G, Cloft HJ. Racial and insurance based disparities in the treatment of carotid artery stenosis: a study of the Nationwide Inpatient Sample. J Neurointerv Surg 2014; 7:695-702. [DOI: 10.1136/neurintsurg-2014-011294] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 06/26/2014] [Indexed: 11/04/2022]
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The impact of insurance status on the outcomes after aneurysmal subarachnoid hemorrhage. PLoS One 2013; 8:e78047. [PMID: 24205085 PMCID: PMC3812119 DOI: 10.1371/journal.pone.0078047] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 09/08/2013] [Indexed: 11/19/2022] Open
Abstract
Investigation into the association of insurance status with the outcomes of patients undergoing neurosurgical intervention has been limited: this is the first nationwide study to analyze the impact of primary payer on the outcomes of patients with aneurysmal subarachnoid hemorrhage who underwent endovascular coiling or microsurgical clipping. The Nationwide Inpatient Sample (2001–2010) was utilized to identify patients; those with both an ICD-9 diagnosis codes for subarachnoid hemorrhage and a procedure code for aneurysm repair (either via an endovascular or surgical approach) were included. Hierarchical multivariate regression analyses were utilized to evaluate the impact of primary payer on in-hospital mortality, hospital discharge disposition, and length of hospital stay with hospital as the random effects variable. Models were adjusted for patient age, sex, race, comorbidities, socioeconomic status, hospital region, location (urban versus rural), and teaching status, procedural volume, year of admission, and the proportion of patients who underwent ventriculostomy. Subsequent models were also adjusted for time to aneurysm repair and time to ventriculostomy; subgroup analyses evaluated for those who underwent endovascular and surgical procedures separately. 15,557 hospitalizations were included. In the initial model, the adjusted odds of in-hospital mortality were higher for Medicare (OR 1.23, p<0.001), Medicaid (OR 1.23, p<0.001), and uninsured patients (OR 1.49, p<0.001) compared to those with private insurance. After also adjusting for timing of intervention, Medicaid and uninsured patients had a reduced odds of non-routine discharge (OR 0.75, p<0.001 and OR 0.42, p<0.001) despite longer hospital stays (by 8.35 days, p<0.001 and 2.45 days, p = 0.005). Variations in outcomes by primary payer–including in-hospital post-procedural mortality–were more pronounced for patients of all insurance types who underwent microsurgical clipping. The observed differences by primary payer are likely multifactorial, attributable to varied socioeconomic factors and the complexities of the American healthcare delivery system.
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Brinjikji W, Rabinstein AA, Lanzino G, Cloft HJ. Racial and Ethnic Disparities in the Treatment of Unruptured Intracranial Aneurysms. Stroke 2012; 43:3200-6. [DOI: 10.1161/strokeaha.112.671214] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Waleed Brinjikji
- From the Department of Radiology (W.B.), Department of Neurology (A.A.R.), Department of Neurosurgery (G.L.), and Department of Radiology (H.J.C.), Mayo Clinic, Rochester, MN
| | - Alejandro A. Rabinstein
- From the Department of Radiology (W.B.), Department of Neurology (A.A.R.), Department of Neurosurgery (G.L.), and Department of Radiology (H.J.C.), Mayo Clinic, Rochester, MN
| | - Giuseppe Lanzino
- From the Department of Radiology (W.B.), Department of Neurology (A.A.R.), Department of Neurosurgery (G.L.), and Department of Radiology (H.J.C.), Mayo Clinic, Rochester, MN
| | - Harry J. Cloft
- From the Department of Radiology (W.B.), Department of Neurology (A.A.R.), Department of Neurosurgery (G.L.), and Department of Radiology (H.J.C.), Mayo Clinic, Rochester, MN
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