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Lala A, Louis C, Vervoort D, Iribarne A, Rao A, Taddei-Peters WC, Raymond S, Bagiella E, O'Gara P, Thourani VH, Badhwar V, Chikwe J, Jessup M, Jeffries N, Moskowitz AJ, Gelijns AC, Rodriguez CJ. Clinical Trial Diversity, Equity, and Inclusion: Roadmap of the Cardiothoracic Surgical Trials Network. Ann Thorac Surg 2024:S0003-4975(24)00200-5. [PMID: 38522771 DOI: 10.1016/j.athoracsur.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/15/2024] [Accepted: 03/06/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND There is a recognized lack of diversity among patients enrolled in cardiovascular interventional and surgical trials. Diverse patient representation in clinical trials is necessary to enhance generalizability of findings, which may lead to better outcomes across broader populations. The Cardiothoracic Surgical Trials Network (CTSN) recently developed a plan of action to increase diversity among participating investigators and trial participants and is the focus of this review. METHODS A review of literature and enrollment data from CTSN trials was conducted. RESULTS CTSN completed more than a dozen major clinical trials (2008-2022), enrolling >4000 patients, of whom 30% were women, 11% were non-White, and 5.6% were Hispanic. CTSN also completed trials of hospitalized patients with coronavirus disease 2019, wherein enrollment was more diverse, with 42% women, and 58% were Asian, Black, Hispanic, or from another underrepresented racial group. The discrepancy in diversity of enrollment between cardiac surgery trials and coronavirus disease trials highlights the need for a more comprehensive understanding of (1) the prevalence of underlying disease requiring cardiac interventions across broad populations, (2) differences in access to care and referral for cardiac surgery, and (3) barriers to enrollment in cardiac surgery trials. CONCLUSIONS Committed to diversity, CTSN's multifaceted action plan includes developing site-specific enrollment targets, collecting social determinants of health data, understanding reasons for nonparticipation, recruiting sites that serve diverse populations, emphasizing greater diversity among clinical trial teams, and implicit bias training. The CTSN will prospectively assess how these interventions influence enrollment as we work to ensure trial participants are more representative of the communities we serve.
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Affiliation(s)
- Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Clauden Louis
- Bostick Heart Center, Department of Cardiovascular and Thoracic Surgery, Winter Haven Hospital, BayCare Health System, Clearwater, Florida
| | - Dominique Vervoort
- Division of Cardiac Surgery and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Alexander Iribarne
- Department of Cardiothoracic Surgery, Staten Island University Hospital, Northwell Health, Staten Island, New York
| | - Aarti Rao
- Zena and Michael A. Wiener Cardiovascular Institute, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Wendy C Taddei-Peters
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Samantha Raymond
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Emilia Bagiella
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Patrick O'Gara
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Joanna Chikwe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Neal Jeffries
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Alan J Moskowitz
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Annetine C Gelijns
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Carlos J Rodriguez
- Department of Medicine (Cardiology), Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Romo Valenzuela A, Chervu NL, Roca Y, Sanaiha Y, Mallick S, Benharash P. Socioeconomic disparities in risk of financial toxicity following elective cardiac operations in the United States. PLoS One 2024; 19:e0292210. [PMID: 38295038 PMCID: PMC10830059 DOI: 10.1371/journal.pone.0292210] [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: 06/09/2023] [Accepted: 09/13/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND While insurance reimbursements allay a portion of costs associated with cardiac operations, uncovered and additional fees are absorbed by patients. An examination of financial toxicity (FT), defined as the burden of patient medical expenses on quality of life, is warranted. Therefore, the present study used a nationally representative database to demonstrate the association between insurance status and risk of financial toxicity (FT) among patients undergoing major cardiac operations. METHODS Adults admitted for elective coronary artery bypass grafting (CABG) and isolated or concomitant valve operations were assessed using the 2016-2019 National Inpatient Sample. FT risk was defined as out-of-pocket expenditure >40% of post-subsistence income. Regression models were developed to determine factors associated with FT risk in insured and uninsured populations. To demonstrate the association between insurance status and risk of FT among patients undergoing major cardiac operations. RESULTS Of an estimated 567,865 patients, 15.6% were at risk of FT. A greater proportion of uninsured patients were at risk of FT (81.3 vs. 14.8%, p<0.001), compared to insured. After adjustment, FT risk among insured patients was not affected by non-income factors. However, Hispanic race (Adjusted Odds Ratio [AOR] 1.60), length of stay (AOR 1.17/day), and combined CABG-valve operations (AOR 2.31, all p<0.05) were associated with increased risk of FT in the uninsured. CONCLUSION Uninsured patients demonstrated higher FT risk after undergoing major cardiac operation. Hispanic race, longer lengths of stay, and combined CABG-valve operations were independently associated with increased risk of FT amongst the uninsured. Conversely, non-income factors did not impact FT risk in the insured cohort. Culturally-informed reimbursement strategies are necessary to reduce disparities in already financially disadvantaged populations.
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Affiliation(s)
- Alberto Romo Valenzuela
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Nikhil L. Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Yvonne Roca
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
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Glance LG, Joynt Maddox KE, Mazzefi M, Knight PW, Eaton MP, Feng C, Kertai MD, Albernathy J, Wu IY, Wyrobek JA, Cevasco M, Desai N, Dick AW. Racial and Ethnic Disparities in Access to Minimally Invasive Mitral Valve Surgery. JAMA Netw Open 2022; 5:e2247968. [PMID: 36542380 PMCID: PMC9857175 DOI: 10.1001/jamanetworkopen.2022.47968] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Whether people from racial and ethnic minority groups experience disparities in access to minimally invasive mitral valve surgery (MIMVS) is not known. OBJECTIVE To investigate racial and ethnic disparities in the utilization of MIMVS. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the Society of Thoracic Surgeons Database for patients who underwent mitral valve surgery between 2014 and 2019. Statistical analysis was performed from January 24 to August 11, 2022. EXPOSURES Patients were categorized as non-Hispanic White, non-Hispanic Black, and Hispanic individuals. MAIN OUTCOMES AND MEASURES The association between MIMVS (vs full sternotomy) and race and ethnicity were evaluated using logistic regression. RESULTS Among the 103 753 patients undergoing mitral valve surgery (mean [SD] age, 62 [13] years; 47 886 female individuals [46.2%]), 10 404 (10.0%) were non-Hispanic Black individuals, 89 013 (85.8%) were non-Hispanic White individuals, and 4336 (4.2%) were Hispanic individuals. Non-Hispanic Black individuals were more likely to have Medicaid insurance (odds ratio [OR], 2.21; 95% CI, 1.64-2.98; P < .001) and to receive care from a low-volume surgeon (OR, 4.45; 95% CI, 4.01-4.93; P < .001) compared with non-Hispanic White individuals. Non-Hispanic Black individuals were less likely to undergo MIMVS (OR, 0.65; 95% CI, 0.58-0.73; P < .001), whereas Hispanic individuals were not less likely to undergo MIMVS compared with non-Hispanic White individuals (OR, 1.08; 95% CI, 0.67-1.75; P = .74). Patients with commercial insurance had 2.35-fold higher odds of undergoing MIMVS (OR, 2.35; 95% CI, 2.06-2.68; P < .001) than those with Medicaid insurance. Patients operated by very-high volume surgeons (300 or more cases) had 20.7-fold higher odds (OR, 20.70; 95% CI, 12.7-33.9; P < .001) of undergoing MIMVS compared with patients treated by low-volume surgeons (less than 20 cases). After adjusting for patient risk, non-Hispanic Black individuals were still less likely to undergo MIMVS (adjusted OR [aOR], 0.88; 95% CI, 0.78-0.99; P = .04) and were more likely to die or experience a major complication (aOR, 1.25; 95% CI, 1.16-1.35; P < .001) compared with non-Hispanic White individuals. CONCLUSIONS AND RELEVANCE In this cross-sectional study, non-Hispanic Black patients were less likely to undergo MIMVS and more likely to die or experience a major complication than non-Hispanic White patients. These findings suggest that efforts to reduce inequity in cardiovascular medicine may need to include increasing access to private insurance and high-volume surgeons.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| | - Karen E. Joynt Maddox
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
- Center for Health Economics and Policy at the Institute for Public Health, Washington University in St Louis, St Louis, Missouri
| | - Michael Mazzefi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville
| | - Peter W. Knight
- Department of Surgery, University of Rochester School of Medicine, Rochester, New York
| | - Michael P. Eaton
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Changyong Feng
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine, Rochester, New York
| | - Miklos D. Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James Albernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins, Baltimore, Maryland
| | - Isaac Y. Wu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Julie A. Wyrobek
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Marisa Cevasco
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
| | - Nimesh Desai
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
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Villarreal ME, Jalilvand A, Schubauer K, Kellet W, DiDonato C, Roberts L, Helkin A, Scarlet S, Wisler J. Comorbidities Matter as Distressed Communities Index Fails to Predict Mortality in Necrotizing Soft Tissue Infection. Surg Infect (Larchmt) 2022; 23:801-808. [DOI: 10.1089/sur.2022.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Anahita Jalilvand
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kathryn Schubauer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Whitney Kellet
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Courtney DiDonato
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Luke Roberts
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alex Helkin
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sara Scarlet
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jonathan Wisler
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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5
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Dekeseredy P, Hickman WP, Fang W, Sedney CL. Traumatic spinal cord injury in West Virginia: Impact on long-term outcomes by insurance status and discharge disposition. J Neurosci Rural Pract 2022; 13:652-657. [PMID: 36743754 PMCID: PMC9893939 DOI: 10.25259/jnrp-2022-3-53-r1-(2492)] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/27/2022] [Indexed: 12/12/2022] Open
Abstract
Objectives Specialized rehabilitation is important for people with traumatic spinal cord injuries (SCIs) to optimize function, independence and mitigate complications, and access to this service varies by the payor. In West Virginia, admission to acute rehabilitation facilities is a "non-covered entity," impeding access to this care for patients with SCI and Medicaid. Our previous work examined the discharge disposition from an acute care hospital of patients with and without Medicaid and found that Medicaid patients were almost twice as likely to be discharged home or to a nursing home, despite similar injury severity and younger age compared to non-Medicaid patients. West Virginia is a largely rural state with multiple health-care challenges. A lack of availability of rehabilitation facilities for Medicaid beneficiaries likely explains this difference. This present study examines the relationship between insurance coverage, discharge disposition at time of injury, and long-term outcomes for people in West Virginia with traumatic SCI. Materials and Methods This study utilized a retrospective chart review and telephone survey from a Level 1 Trauma Center in West Virginia. Participants included 200 patients with traumatic SCI from 2009 to 2016 in West Virginia. Thirty-four patients completed the survey through telephone interviews, with another 16 completing the survey but declining to answer economic questions. Survey participants were asked the Craig Handicap Assessment and Reporting Technique (CHART), which indicates the degree of impairment, and disability; they experience years after initial injury and rehabilitation. Proportional odds regression models, a regression model generalization of the Wilcoxon rank sum test, were employed where normal distribution of the response variables was not assumed and was performed, controlling for age and injury severity. Results Total CHART score correlated with discharge disposition (P = 0.01). Insurance type correlated with mobility sub-score (P = 0.03). Conclusion Patients discharged to a rehabilitation center have overall higher CHART scores post-injury, indicating better long-term outcomes than those discharged home or a nursing home. People with Medicaid as payors had lower scores for mobility than those with other insurance coverage.
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Affiliation(s)
| | | | - Wei Fang
- West Virginia Clinical and Translational Science Institute, Erma Byrd Biomedical Research Center, Morgantown, West Virginia
| | - Cara L. Sedney
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
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6
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Frankel WC, Sylvester CB, Asokan S, Ryan CT, Zea-Vera R, Zhang Q, Wall MJ, Preventza O, Coselli JS, Rosengart TK, Chatterjee S, Ghanta RK. Outcomes, Cost, and Readmission After Surgical Aortic or Mitral Valve Replacement at Safety-Net and Non-Safety-Net Hospitals. Ann Thorac Surg 2022; 114:703-709. [PMID: 35202596 PMCID: PMC9413024 DOI: 10.1016/j.athoracsur.2022.01.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/10/2022] [Accepted: 01/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Safety-net hospitals provide essential services to vulnerable patients with complex medical and socioeconomic circumstances. We hypothesized that matched patients at safety-net hospitals and non-safety-net hospitals would have comparable outcomes, costs, and readmission rates after isolated surgical aortic valve replacement (AVR) or mitral valve replacement (MVR). METHODS The National Readmissions Database was queried to identify patients who underwent isolated AVR (n = 109 744) or MVR (n = 31 475) from 2016 to 2018. Safety-net burden was defined as the percentage of patients who were uninsured or insured with Medicaid, with hospitals in the top quartile designated as safety-net hospitals. After propensity score matching, outcomes for AVR and MVR at safety-net hospitals vs non-safety-net hospitals were compared. RESULTS Overall, 17 925 AVRs (16%) and 5516 MVRs (18%) were performed at safety-net hospitals, and these patients had higher comorbidity rates, had lower socioeconomic status, and more frequently required urgent surgery. Observed inhospital mortality was similar between safety-net hospitals and non-safety-net hospitals (AVR 2.2% vs 2.1%, P = .4; MVR 4.8% vs 4.3%, P = .1). After matching, rates of inhospital mortality, major morbidity, and readmission were similar; however, safety-net hospitals had longer length of stay after AVR (7 vs 6 days, P = .001) and higher total cost after AVR ($49 015 vs $42 473, P < .001) and MVR ($59 253 vs $52 392, P < .001). CONCLUSIONS Isolated surgical AVR and MVR are both performed at safety-net hospitals with outcomes comparable to those at non-safety-net hospitals, supporting efforts to expand access to these procedures for underserved populations. Investment in care coordination resources to reduce length of stay and curtail cost at safety-net hospitals is warranted.
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Affiliation(s)
- William C Frankel
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Christopher B Sylvester
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Medical Scientist Training Program, Baylor College of Medicine, Houston, Texas; Department of Bioengineering, Rice University, Houston, Texas
| | - Sainath Asokan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Christopher T Ryan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Rodrigo Zea-Vera
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Qianzi Zhang
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Mathew J Wall
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Todd K Rosengart
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Ravi K Ghanta
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas.
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7
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Huckaby LV, Hardy WA, Walkowiak OA, Gregoski M, Mokashi S, Kilic A, Greenwood B, Rajab TK. Recipient-surgeon racial concordance in orthotopic heart transplantation outcomes. J Card Surg 2022; 37:2247-2257. [PMID: 35526128 DOI: 10.1111/jocs.16573] [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: 01/30/2022] [Accepted: 02/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prior studies have demonstrated deleterious outcomes for physician-patient racial discordance. We explored recipient-surgeon racial concordance and short-term postoperative survival in adults undergoing orthotopic heart transplantation (OHT). METHODS The United Network for Organ Sharing (UNOS) database was queried to identify White and Black adult (≥18 years) patients undergoing isolated OHT between 2000 and 2020. Surgeon race was obtained from publicly available images. All non-White and non-Black recipients and surgeons were excluded. Linear probability models were utilized to explore the relationship between recipient-surgeon racial concordance and 30-, 60-, and 90-day post-transplant mortality using a fixed effects approach. RESULTS A total of 26,133 recipients were identified (mean age 52.79 years, 74.4% male) with 77.65% (n = 20,292) being White and 22.35% (n = 5841) being Black. A total of 662 White surgeons performed 25,946 (97.56%) OHTs during the study period while 17 Black surgeons performed 437 (1.67%) OHTs. Although some evidence of differences across groups was observed in cross-tabular specifications, these differences became insignificant after the inclusion of controls (i.e., comorbidities and fixed effects). This suggests that recipient race and physician race are not correlated with post-OHT survival at 30, 60, or 90 days. CONCLUSIONS Recipient-surgeon racial concordance and discordance among adults undergoing OHT do not appear to impact post-transplant survival. Nor do we observe significant penalties accruing for Black patients overall once controls are accounted for. Given that worse outcomes have historically been demonstrated for Black patients undergoing OHT, further work will be necessary to improve understanding of racial disparities for patients with end-stage heart failure.
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Affiliation(s)
- Lauren V Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - William A Hardy
- Section of Pediatric Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Olivia A Walkowiak
- Section of Pediatric Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mathew Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Suyog Mokashi
- Division of Cardiac Surgery, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brad Greenwood
- School of Business, George Mason University, Fairfax, Virginia, USA
| | - Taufiek K Rajab
- Section of Pediatric Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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8
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Mehaffey JH, Cullen JM, Hawkins RB, Fonner C, Kern J, Speir A, Quader M, Ailawadi G, Teman N, Yarboro L. Access to Left Ventricular Assist Device: Travel Time Does Not Tell The Whole Story. J Surg Res 2021; 271:52-58. [PMID: 34837734 DOI: 10.1016/j.jss.2021.10.022] [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: 01/22/2021] [Revised: 10/13/2021] [Accepted: 10/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Negative health effects of traveling longer distances for surgical services have been reported. Given the high complexity of multidisciplinary care required for management of Left Ventricular Assist Device (LVAD) implantation, only 4 of 18 centers in our state perform these operations. Given the limited access we hypothesized increased travel time would adversely affect postoperative outcomes and 30-d mortality. METHODS A statewide Society of Thoracic Surgeons database was queried to identify patients undergoing Heartmate II/III and HVAD implantation, and 725 patients were identified. Travel time was calculated by zip code. Patients were stratified into regional and distant groups by the upper quartile of travel time (1-h). Preoperative variables and outcomes were compared between the groups. Multivariate analysis was performed to evaluate the impact of travel time in risk-adjusted models of 30-d mortality. RESULTS Median patient travel time to their LVAD center in our state is 32 min (mean 53 ± 65 min, 46 ± 71 miles). Patients in the distant group (n = 191) had lower median incomes, higher self-pay status, higher rates of medical comorbid disease. Despite these differences there was no difference between the groups in ICU and/or hospital length of stay, readmission, postoperative complications, or 30-d mortality. Multivariate regression demonstrated insurance status, age, and prior surgery predicted 30-d mortality, but not travel time. CONCLUSIONS Despite only four centers in the state performing LVAD implantation, travel time was strongly associated with preoperative risk, and socioeconomic status but not postoperative outcomes or 30-d mortality. Therefore, increasing access should focus on insurance, and patient characteristics not travel time.
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Affiliation(s)
- J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - J Michael Cullen
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Clifford Fonner
- Virginia Cardiac Surgery Quality Initiative, Falls Church, Virginia
| | - John Kern
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Alan Speir
- INOVA Heart and Vascular Institute, Falls Church, Virginia
| | - Mohammed Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Nicholas Teman
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Leora Yarboro
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
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9
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The Influence of Household Income on Survival following Posterior Fossa Tumor Resection at a Large Academic Medical Center. J Neurol Surg B Skull Base 2021; 82:631-637. [PMID: 34745830 DOI: 10.1055/s-0040-1715590] [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: 02/28/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022] Open
Abstract
Objectives The present study examines the effect of median household income on mid- and long-term outcomes in a posterior fossa brain tumor resection population. Design This is a retrospective regression analysis. Setting The study conducted at a single, multihospital, urban academic medical center. Participants A total of 283 consecutive posterior fossa brain tumor cases, excluding cerebellar pontine angle tumors, over a 6-year period (June 09, 2013-April 26, 2019) was included in this analysis. Main Outcome Measures Outcomes studied included 90-day readmission, 90-day emergency department evaluation, 90-day return to surgery, reoperation within 90 days after index admission, reoperation throughout the entire follow-up period, mortality within 90 days, and mortality throughout the entire follow-up period. Univariate analysis was conducted for the whole population and between the lowest (Q1) and highest (Q4) socioeconomic quartiles. Stepwise regression was conducted to identify confounding variables. Results Lower socioeconomic status was found to be correlated with increased mortality within 90 postoperative days and throughout the entire follow-up period. Similarly, analysis between the lowest and highest household income quartiles (Q1 vs. Q4) demonstrated Q4 to have significantly decreased mortality during total follow-up and a decreasing but not significant difference in 90-day mortality. No significant difference in morbidity was observed. Conclusion This study suggests that lower household income is associated with increased mortality in both the 90-day window and total follow-up period. It is possible that there is an opportunity for health care providers to use socioeconomic status to proactively identify high-risk patients and provide additional resources in the postoperative setting.
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Haldar D, Glauser G, Schuster JM, Winter E, Goodrich S, Shultz K, Brem S, McClintock SD, Malhotra NR. Role of Race in Short-Term Outcomes for 1700 Consecutive Patients Undergoing Brain Tumor Resection. J Healthc Qual 2021; 43:284-291. [PMID: 32544138 DOI: 10.1097/jhq.0000000000000267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Access to medical care seems to be impacted by race. However, the effect of race on outcomes, once care has been established, is poorly understood. PURPOSE This study seeks to assess the influence of race on patient outcomes in a brain tumor surgery population. IMPORTANCE AND RELEVANCE TO HEALTHCARE QUALITY This study offers insights to if or how quality is impacted based on patient race, after care has been established. Knowledge of disparities may serve as a valuable first step toward risk factor mitigation. METHODS Patients differing in race, but matched on other outcomes affecting characteristics, were assessed for differences in outcomes subsequent to brain tumor resection. Coarsened exact matching was used to match 1700 supratentorial brain tumor procedures performed over a 6-year period at a single, multihospital academic medical center. Patient outcomes assessed included unplanned readmission, mortality, emergency department (ED) visits, and unanticipated return to surgery. RESULTS There was no significant difference in readmissions, mortality, ED visits, return to surgery after index admission, or return to surgery within 30 days between the two races. CONCLUSION This study suggests that race does not independently influence postsurgical outcomes but may instead serve as a proxy for other closely related demographics.
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11
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Spring AM, Catalano MA, Rutkin B, Hartman A, Yu PJ. Racial and socioeconomic disparities in urgent transcatheter mitral valve repair: A National Inpatient Sample analysis. J Card Surg 2021; 36:3224-3229. [PMID: 34110045 DOI: 10.1111/jocs.15735] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/14/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cardiac interventions performed urgently are known to be associated with poor outcomes compared with electively performed procedures. Transcatheter edge-to-edge mitral valve repair (TMVr) has developed as a reasonable alternative to mitral valve surgery in certain patient populations. We aimed to leverage a national database to identify predictors of urgent versus elective TMVr, as well as the association between urgency and outcomes. METHODS The National Inpatient Sample (NIS) was queried to identify patients who underwent TMVr from 2016 to 2017. Hospitalizations were identified within the database as elective versus nonelective. Univariate and multivariable analyses were performed to identify patient characteristics associated with urgent procedures. In-hospital outcomes were assessed. RESULTS There were 10,195 cases of TMVr in this cohort, 24.2% of which were performed urgently. In multivariable analysis, Hispanic race, Medicaid insurance, and low income were associated with increased likelihood of urgent hospital admission and TMVr. Additionally, small hospital size and Northeast region were associated with increased likelihood of urgent admission and procedure. Urgent TMVr was associated with increased mortality (4.5% vs. 1.6%, p < .001), prolonged length of stay (6.0 vs. 2.0, p < .001), and increased cost ($71,451.90 vs. $44,981.20, p < .001). CONCLUSIONS Racial and socioeconomic disparities exist in the utilization of TMVr as an urgent versus elective procedure, suggesting differences in access to surveillance and preventive care. Urgent TMVr is associated with increased morbidity and mortality, prolonged length of stay, and increased hospital costs. Priority should be placed on mitigating such disparities to improve outcomes.
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Affiliation(s)
- Alexander M Spring
- Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Michael A Catalano
- Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Bruce Rutkin
- Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Alan Hartman
- Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Pey-Jen Yu
- Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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12
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Khatana SAM, Hanff TC, Nathan AS, Dayoub EJ, Grandin EW, Rame JE, Fanaroff AC, Giri J, Groeneveld PW. Association of Health Insurance Payer Type and Outcomes After Durable Left Ventricular Assist Device Implantation: An Analysis of the STS-INTERMACS Registry. Circ Heart Fail 2021; 14:e008277. [PMID: 33993721 DOI: 10.1161/circheartfailure.120.008277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Due to the high cost of left ventricular assist device (LVAD) therapy, payer type may be an important factor in determining eligibility. How payer type influences outcomes after LVAD implantation is unclear. We, therefore, aimed to study the association of health insurance payer type with outcomes after durable LVAD implantation. METHODS Using STS-INTERMACS (Society of Thoracic Surgeons-Interagency Registry for Mechanically Assisted Circulatory Support), we studied nonelderly adults receiving a durable LVAD from 2016 to 2018 and compared all-cause mortality and postindex hospitalization adverse event episode rate by payer type. Multivariable Fine-Gray and generalized linear models were used to compare the outcomes. RESULTS Of the 3251 patients included, 26.0% had Medicaid, 24.9% had Medicare alone, and 49.1% had commercial insurance. Compared with commercially insured patients, mortality did not differ for patients with Medicaid (subdistribution hazard ratio, 1.00 [95% CI, 0.75-1.34], P=0.99) or Medicare (subdistribution hazard ratio, 1.09 [95% CI, 0.84-1.41], P=0.52). Medicaid was associated with a significantly lower adjusted incidence rate (incidence rate ratio, 0.88 [95% CI, 0.78-0.99], P=0.041), and Medicare was associated with a significantly higher adjusted incidence rate (incidence rate ratio, 1.16 [95% CI, 1.03-1.30], P=0.011) of adverse event episodes compared with commercially insured patients. CONCLUSIONS All-cause mortality after durable LVAD implantation did not differ significantly by payer type. Payer type was associated with the rate of adverse events, with Medicaid associated with a significantly lower rate, and Medicare with a significantly higher rate of adverse event episodes compared with commercially insured patients.
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Affiliation(s)
- Sameed Ahmed M Khatana
- Division of Cardiovascular Medicine (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,The Leonard Davis Institute of Health Economics (S.A.M.K., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA
| | - Thomas C Hanff
- Division of Cardiovascular Medicine (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA
| | - Ashwin S Nathan
- Division of Cardiovascular Medicine (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,The Leonard Davis Institute of Health Economics (S.A.M.K., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA
| | - Elias J Dayoub
- Division of Cardiovascular Medicine (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,The Leonard Davis Institute of Health Economics (S.A.M.K., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA
| | - E Wilson Grandin
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology (E.W.G.), Beth Israel Deaconess Medical Center, Boston, MA.,Division of Cardiology (E.W.G.), Beth Israel Deaconess Medical Center, Boston, MA
| | - J Eduardo Rame
- Jefferson Heart Institute, Thomas Jefferson University Hospital, Pennsylvania, PA (J.E.R.)
| | - Alexander C Fanaroff
- Division of Cardiovascular Medicine (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,The Leonard Davis Institute of Health Economics (S.A.M.K., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA
| | - Jay Giri
- Division of Cardiovascular Medicine (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,The Leonard Davis Institute of Health Economics (S.A.M.K., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,The Leonard Davis Institute of Health Economics (S.A.M.K., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Division of General Internal Medicine, Perelman School of Medicine (P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Pennsylvania, PA (P.W.G.)
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Ahmed I, Merchant FM, Curtis JP, Parzynski CS, Lampert R. Impact of insurance status on ICD implantation practice patterns: Insights from the NCDR ICD registry. Am Heart J 2021; 235:44-53. [PMID: 33503408 DOI: 10.1016/j.ahj.2021.01.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Whether insurance status influences practice patterns in implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) defibrillators, when indicated, is not known. METHODS AND RESULTS We analyzed the NCDR ICD Registry to evaluate associations of insurance status with guidelines-based receipt of CRT, as well as device-type, complication rates, and use of optimal medical therapy defined by guidelines. Among 798,028 patients with de novo ICD implants, we included only patients < 65 years (those older have Medicare) and excluded those admitted before 2006 (n=1,835) or with insurance coverage other than Medicare, Medicaid or private insurance (n=25,695) leaving 286,556 for analysis. Inverse probability of treatment weighting was used to control for imbalances between groups. Mean age was 53 years, 29% were female. Patients with private insurance and Medicare were more likely to receive CRT-D when indicated (79.6%, OR 1.19 95% CI 1.09-1.28, P <.001 and 78.5%, OR 1.11 95% CI 1.01-1.21 P = .03, respectively) compared to the uninsured (76.7%). The uninsured were also more likely than other groups to receive a single-chamber device. Complication rates did not differ. Uninsured patients were, however, more likely to receive optimal medical therapy, particularly in the subgroup receiving the implant for primary prevention. CONCLUSIONS In propensity-weighted analysis, uninsured patients are less likely to receive CRT when indicated but more likely to be receiving optimal medical therapy at discharge. Reasons for differences in device implantation practices based on insurance status require further study.
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14
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Wong JH, Irish WD, DeMaria EJ, Vohra NA, Pories WJ, Brownstein MR, Altieri MS, Akram W, Haisch CE, Leeser DB, Tuttle JE. Development and Assessment of a Systematic Approach for Detecting Disparities in Surgical Access. JAMA Surg 2021; 156:239-245. [PMID: 33326009 DOI: 10.1001/jamasurg.2020.5668] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Although optimal access is accepted as the key to quality care, an accepted methodology to ascertain potential disparities in surgical access has not been defined. Objective To develop a systematic approach to detect surgical access disparities. Design, Setting, and Participants This cross-sectional study used publicly available data from the Health Cost and Utilization Project State Inpatient Database from 2016. Using the surgical rate observed in the 5 highest-ranked counties (HRCs), the expected surgical rate in the 5 lowest-ranked counties (LRCs) in North Carolina were calculated. Patients 18 years and older who underwent an inpatient general surgery procedure and patients who underwent emergency inpatient cholecystectomy, herniorrhaphy, or bariatric surgery in 2016 were included. Data were collected from January to December 2016, and data were analyzed from March to July 2020. Exposures Health outcome county rank as defined by the Robert Wood Johnson Foundation. Main Outcomes and Measures The primary outcome was the proportional surgical ratio (PSR), which was the disparity in surgical access defined as the observed number of surgical procedures in the 5 LRCs relative to the expected number of procedures using the 5 HRCs as the standardized reference population. Results In 2016, approximately 1.9 million adults lived in the 5 HRCs, while approximately 246 854 lived in the 5 LRCs. A total of 28 924 inpatient general surgical procedures were performed, with 4521 being performed in those living in the 5 LRCs and 24 403 in those living in the 5 HRCs. The rate of general surgery in the 5 HRCs was 13.09 procedures per 1000 population. Using the 5 HRCs as the reference, the PSR for the 5 LRCs was 1.40 (95% CI, 1.35-1.44). For emergent/urgent cholecystectomy, the PSR for the 5 LRCs was 2.26 (95% CI, 2.02-2.51), and the PSR for emergent/urgent herniorrhaphy was 1.83 (95% CI, 1.33-2.45). Age-adjusted rate of obesity (body mass index [calculated as weight in kilograms divided by height in meters squared] greater than 30), on average, was 36.6% (SD, 3.4) in the 5 LRCs vs 25.4% (SD, 4.6) in the 5 HRCs (P = .002). The rate of bariatric surgery in the 5 HRCs was 33.07 per 10 000 population with obesity. For the 5 LRCs, the PSR was 0.60 (95% CI, 0.51-0.69). Conclusions and Relevance The PSR is a systematic approach to define potential disparities in surgical access and should be useful for identifying, investigating, and monitoring interventions intended to mitigate disparities in surgical access that effects the health of vulnerable populations.
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Affiliation(s)
- Jan H Wong
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - William D Irish
- Division of Surgical Research, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina.,Department of Public Health, East Carolina University, Greenville, North Carolina
| | - Eric J DeMaria
- Division of General Minimal Invasive and Bariatric Surgery, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Nasreen A Vohra
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Walter J Pories
- Division of Surgical Research, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Michelle R Brownstein
- Division of Trauma and Critical Care, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Maria S Altieri
- Division of General Minimal Invasive and Bariatric Surgery, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Warqaa Akram
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Carl E Haisch
- Division of Surgical Immunology and Transplantation, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - David B Leeser
- Division of Surgical Immunology and Transplantation, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Janet E Tuttle
- Division of Surgical Immunology and Transplantation, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
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15
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Haldar D, Glauser G, Winter E, Dimentberg R, Goodrich S, Shultz K, McClintock SD, Malhotra NR. The influence of race on outcomes following pituitary tumor resection. Clin Neurol Neurosurg 2021; 203:106558. [PMID: 33640561 DOI: 10.1016/j.clineuro.2021.106558] [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: 04/15/2020] [Revised: 01/25/2021] [Accepted: 02/06/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the influence of race on short-term patient outcomes in a pituitary tumor surgery population. PATIENTS AND METHODS Coarsened exact matching was used to retrospectively analyze consecutive patients (n = 567) undergoing pituitary tumor resection over a six-year period (June 07, 2013 to April 29, 2019) at a single, multi-hospital academic medical center. Black/African American and white patients were exact matched based on twenty-nine (29) patient, procedure, and hospital characteristics. Matching characteristics included surgical costs, American Society of Anesthesiologists grade, duration of surgery, and Charlson Comorbidity Index, amongst others. Outcomes studied included unplanned 90-day readmission, emergency room (ER) evaluation, and unplanned reoperation. RESULTS Ninety-two (n = 92) patients were exact matched and analyzed. There was no significant difference in 90-day readmission (p = 0.267, OR (black/AA vs white) = 0.500, 95% CI = 0.131-1.653) or ER evaluation within 90 days (p = 0.092, OR = 3.000, 95% CI = 0.848-13.737) between the two cohorts. Furthermore, there was no significant difference in the rate of unplanned reoperation throughout the duration of the follow up period between matched black/African American and white patients (p = 0.607, OR = 0.750, 95% CI = 0.243-2.211). CONCLUSION This study suggests that the effect of race on post-operative outcomes is largely mitigated when equal access is attained, and when race is effectively isolated from socioeconomic factors and comorbidities in a population undergoing pituitary tumor resection.
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Affiliation(s)
- Debanjan Haldar
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, 3rd Floor Silverstein Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, United States
| | - Gregory Glauser
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, 3rd Floor Silverstein Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, United States
| | - Eric Winter
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, 3rd Floor Silverstein Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, United States
| | - Ryan Dimentberg
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, 3rd Floor Silverstein Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, United States
| | - Stephen Goodrich
- McKenna EpiLog Fellowship in Population Health at the University of Pennsylvania, Philadelphia, PA, United States; West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, PA, United States
| | - Kaitlyn Shultz
- McKenna EpiLog Fellowship in Population Health at the University of Pennsylvania, Philadelphia, PA, United States; West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, PA, United States
| | - Scott D McClintock
- West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, PA, United States
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, 3rd Floor Silverstein Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, United States.
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Benedetto U, Dimagli A, Gibbison B, Sinha S, Pufulete M, Fudulu D, Cocomello L, Bryan AJ, Ohri S, Caputo M, Cooper G, Dong T, Akowuah E, Angelini GD. Disparity in clinical outcomes after cardiac surgery between private and public (NHS) payers in England. THE LANCET REGIONAL HEALTH. EUROPE 2021; 1:100003. [PMID: 35104303 PMCID: PMC8454835 DOI: 10.1016/j.lanepe.2020.100003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND There is little known about how payer status impacts clinical outcomes in a universal single-payer system such as the UK National Health Service (NHS). The aim of this study was to evaluate the relationship between payer status (private or public) and clinical outcomes following cardiac surgery from NHS providers in England. METHODS The National Adult Cardiac Surgery Audit (NACSA) registry was interrogated for patients who underwent adult cardiac surgery in England from 2009 to 2018. Information on socioeconomic status were provided by linkage with the Iteration of the English Indices of Deprivation (IoD). The primary outcome was in-hospital mortality. Secondary outcomes included incidence of in-hospital postoperative cerebrovascular accident (CVA), renal dialysis, sternal wound infection, and re-exploration. To assess whether payer status was an independent predictor of in-hospital mortality, binomial generalized linear mixed models (GLMM) were fitted along with 17 items forming the EuroSCORE and the IoD domains. FINDINGS The final sample consisted of 280,209 patients who underwent surgery in 31 NHS hospitals in England from 2009 to 2018. Of them, 5,967 (2.1%) and 274,242 (97.9%) were private and NHS payers respectively. Private payer status was associated with a lower risk of in-hospital mortality (OR 0.79; 95%CI 0.65 - 0.97;P = 0.026), CVA (OR 0.77; 95%CI 0.60 - 0.99; P = 0.039), need for re-exploration (OR 0.84; 95%CI 0.72 - 0.97; P = 0.017) and with non-significant lower risk of dialysis (OR 0.84; 95%CI 0.69 - 1.02; P = 0.074). Private payer status was found to be independently associated with lower risk of in-hospital mortality in the elective subgroup (OR 0.76; 95%CI 0.61 - 0.96; P = 0.020) but not in the non-elective subgroup (OR 1.01; 95%CI 0.64 - 1.58; P = 0.976). INTERPRETATION In conclusion, using a national database, we have found evidence of significant beneficial effect of payer status on hospital outcomes following cardiac surgery in favour of private payers regardless their socioeconomic factors.
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Affiliation(s)
- Umberto Benedetto
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Arnaldo Dimagli
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Ben Gibbison
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Shubhra Sinha
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Maria Pufulete
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol, UK
| | - Daniel Fudulu
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Lucia Cocomello
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Alan J. Bryan
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Sunil Ohri
- Wessex Cardiothoracic Centre, Southampton University Hospitals NHS Trust, Southampton, UK
| | - Massimo Caputo
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Graham Cooper
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
| | - Tim Dong
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Enoch Akowuah
- James Cook Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Gianni D. Angelini
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, UK
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Hammarlund N. Racial treatment disparities after machine learning surgical risk-adjustment. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2021. [DOI: 10.1007/s10742-020-00231-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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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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Hoyler MM, Feng TR, Ma X, Rong LQ, Avgerinos DV, Tam CW, White RS. Insurance Status and Socioeconomic Factors Affect Early Mortality After Cardiac Valve Surgery. J Cardiothorac Vasc Anesth 2020; 34:3234-3242. [DOI: 10.1053/j.jvca.2020.03.044] [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: 02/23/2020] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 12/13/2022]
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Smith BC, Morrison CP, Pauls RN. Complications and Month of Surgery: Does Scheduling Make a Difference? J Gynecol Surg 2020. [DOI: 10.1089/gyn.2020.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Benjamin C. Smith
- Division of Female Pelvic Medicine and Reconstructive Surgery, TriHealth, Good Samaritan Hospital, Cincinnati, Ohio, USA
| | - Christopher P. Morrison
- Division of Obstetrics and Gynecology, TriHealth, Good Samaritan Hospital, Cincinnati, Ohio, USA
| | - Rachel N. Pauls
- Division of Female Pelvic Medicine and Reconstructive Surgery, TriHealth, Good Samaritan Hospital, Cincinnati, Ohio, USA
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Zhang GQ, Canner JK, Haut E, Sherman RL, Abularrage CJ, Hicks CW. Impact of Geographic Socioeconomic Disadvantage on Minor Amputation Outcomes in Patients With Diabetes. J Surg Res 2020; 258:38-46. [PMID: 32980774 DOI: 10.1016/j.jss.2020.08.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/13/2020] [Accepted: 08/30/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Socioeconomic disadvantage is a known contributor to adverse events and higher admission rates in the diabetic population. However, its impact on outcomes after lower extremity amputation is unclear. We aimed to assess the association of geographic socioeconomic disadvantage with short- and long-term outcomes after minor amputation in patients with diabetes. MATERIALS AND METHODS Geographic socioeconomic disadvantage was determined using the area deprivation index (ADI). All patients from the Maryland Health Services Cost Review Commission database (2012-2019) who underwent minor amputation with a concurrent diagnosis of diabetes were included and stratified by the ADI quartile. Associations of the ADI quartile with 30-day readmission and 1-year reamputation were evaluated using Kaplan-Meier survival analyses and multivariable logistic regression models adjusting for baseline differences. RESULTS A total of 7415 patients with diabetes underwent minor amputation (70.1% male, 38.7% black race), including 28.1% ADI1 (least deprived), 42.8% ADI2, 22.9% ADI3, and 6.2% ADI4 (most deprived). After adjusting for demographic and clinical factors, the odds of 30-day readmission were greater in the intermediate ADI groups than those in the ADI1 group, but not among the most deprived. Adjusted odds of 1-year reamputation were greater among ADI4 than those among ADI1. Kaplan-Meier analysis confirmed a greater likelihood of reamputation with an increasing ADI quartile over a 1-year period (P < 0.001). CONCLUSIONS Geographic socioeconomic disadvantage is independently associated with both short- and long-term outcomes after minor diabetic amputations in Maryland. A targeted approach addressing the health care needs of deprived regions may be beneficial in optimizing postoperative care in this vulnerable population.
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Affiliation(s)
- George Q Zhang
- The Johns Hopkins University School of Medicine, Baltimore, Maryland; Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Elliott Haut
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland; Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Ronald L Sherman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Caitlin W Hicks
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.
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Haldar D, Glauser G, Winter E, Goodrich S, Shultz K, McClintock SD, Malhotra NR. Assessing the Role of Patient Race in Disparity of 90-Day Brain Tumor Resection Outcomes. World Neurosurg 2020; 139:e663-e671. [PMID: 32360924 DOI: 10.1016/j.wneu.2020.04.098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study assesses the influence of race on patient outcomes in a brain tumor surgery population. METHODS Coarsened exact matching was used to retrospectively analyze 1700 supratentorial brain tumor procedures over a 6-year period (June 7, 2013 to April 29, 2019) at a single, multihospital academic medical center. Outcome measures included readmission, mortality, emergency room visits, and reoperation. RESULTS McNemar test (mid-P) showed no significant difference in 90-day mortality between the 2 races (P = 0.3018). However, there was a significant difference in 90-day readmissions between the 2 races (P = 0.0237). There was no significant difference in 90-day emergency room visits (P = 0.0579), 90-day return to surgery after index admission (P = 0.6015), or return to surgery within 90 days (P = 0.6776) between the 2 races. There was also no significant difference in return to surgery for the duration of the follow-up period (P = 0.8728). CONCLUSIONS This study suggests that race alone does not result in disparate outcomes; however, there was an associated difference in 90-day postsurgical readmissions. Despite coarsened exact matching, persistent differences in median household income may play a role in the disparate outcome noted.
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Affiliation(s)
- Debanjan Haldar
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Gregory Glauser
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Eric Winter
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Stephen Goodrich
- McKenna EpiLog Fellowship in Population Health at the University of Pennsylvania, Philadelphia, USA; West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, Pennsylvania, USA
| | - Kaitlyn Shultz
- McKenna EpiLog Fellowship in Population Health at the University of Pennsylvania, Philadelphia, USA; West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, Pennsylvania, USA
| | - Scott D McClintock
- West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, Pennsylvania, USA
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
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Chatterjee S, LeMaire SA, Amarasekara HS, Green SY, Wei Q, Zhang Q, Price MD, Jesudasen S, Woodside SJ, Preventza O, Coselli JS. Differential presentation in acuity and outcomes based on socioeconomic status in patients who undergo thoracoabdominal aortic aneurysm repair. J Thorac Cardiovasc Surg 2020; 163:1990-1998.e1. [DOI: 10.1016/j.jtcvs.2020.07.073] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/17/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
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24
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The Effect of Race on Short-Term Pituitary Tumor Outcomes. World Neurosurg 2020; 137:e447-e453. [DOI: 10.1016/j.wneu.2020.01.241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 11/19/2022]
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25
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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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26
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Hoyler MM, White RS, Tam CW. Enhanced Recovery After Surgery Protocols May Help Reduce Racial and Socioeconomic Disparities in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:569-570. [DOI: 10.1053/j.jvca.2019.07.144] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 07/26/2019] [Indexed: 12/17/2022]
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Sedney CL, Khan U, Dekeseredy P. Traumatic spinal cord injury in West Virginia: Disparities by insurance and discharge disposition from an acute care hospital. J Spinal Cord Med 2020; 43:106-110. [PMID: 30508405 PMCID: PMC7006673 DOI: 10.1080/10790268.2018.1544878] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Context: Medicaid has been linked to worse outcomes in a variety of diagnoses such as lung cancer, uterine cancer, and cardiac valve procedures. It has furthermore been linked to the reduced health-related quality of life outcomes after traumatic injuries when compared to other insurance groups. In spinal cord injury (SCI), the care provided in the subacute setting may vary based upon payor status, which may have implications on outcomes and cost of care.Design: A retrospective review utilizing the institutional trauma databank was performed for all adult patients with spinal cord injury since 2009. Pediatric patients were excluded. Insurance type, race, length of stay, discharge status (alive/dead), discharge disposition, injury severity score (ISS), and hospital charges billed were recorded.Results: Two hundred patients were identified. Overall 27.5% of patients with SCI during the period of our review were Medicaid beneficiaries. ISS was similar between Medicaid and non-Medicaid patients, but the Medicaid beneficiaries were younger (37 vs 50 years of age; P < .001). Medicaid beneficiaries had a significantly longer length of stay (20.9 days; P < .001) when compared to all other patients. They furthermore were more likely to be discharged home or to a skilled nursing facility rather than an acute rehabilitation center. Inpatient charges billed for Medicaid beneficiaries were significantly higher than those of non-Medicaid patients (203,264 USD vs 140,114 USD; P = .015), likely reflecting the increased length of stay while awaiting appropriate disposition.Conclusion: Medicaid patients with SCI in West Virginia had a longer hospital stay, higher charges billed, and were more likely to be discharged home or to a skilled nursing facility rather than an acute rehabilitation center, when compared to non-Medicaid patients. The lack of availability of rehabilitation facilities for Medicaid beneficiaries likely explains this difference.
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Affiliation(s)
- Cara L. Sedney
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA
| | - Uzer Khan
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
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Single-payer or a multipayer health system: a systematic literature review. Public Health 2018; 163:141-152. [PMID: 30193174 DOI: 10.1016/j.puhe.2018.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 04/18/2018] [Accepted: 07/09/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Healthcare systems worldwide are actively exploring new approaches for cost containment and efficient use of resources. Currently, in a number of countries, the critical decision to introduce a single-payer over a multipayer healthcare system poses significant challenges. Consequently, we have systematically explored the current scientific evidence about the impact of single-payer and multipayer health systems on the areas of equity, efficiency and quality of health care, fund collection negotiation, contracting and budgeting health expenditure and social solidarity. STUDY DESIGN This is a systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. METHODS A search for relevant articles published in English was performed in March 2015 through the following databases: Excerpta Medica Databases, Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online through PubMed and Ovid, Health Technology Assessment Database, Cochrane database and WHO publications. We also searched for further articles cited by eligible papers. RESULTS A total of 49 studies were included in the analysis; 34 studied clinical outcomes of patients enrolled in different health insurances, while 15 provided a qualitative assessment in this field. CONCLUSION The single-payer system performs better in terms of healthcare equity, risk pooling and negotiation, whereas multipayer systems yield additional options to patients and are harder to be exploited by the government. A multipayer system also involves a higher administrative cost. The findings pertaining to the impact on efficiency and quality are rather tentative because of methodological limitations of available studies.
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McCutcheon BA, Hirshman BR, Gabel BC, Heffner MW, Marcus LP, Cole TS, Chen CC, Chang DC, Carter BS. Impact of neurosurgeon specialization on patient outcomes for intracranial and spinal surgery: a retrospective analysis of the Nationwide Inpatient Sample 1998–2009. J Neurosurg 2018; 128:1578-1588. [DOI: 10.3171/2016.4.jns152332] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe subspecialization of neurosurgical practice is an ongoing trend in modern neurosurgery. However, it remains unclear whether the degree of surgeon specialization is associated with improved patient outcomes. The authors hypothesized that a trend toward increased neurosurgeon specialization was associated with improved patient morbidity and mortality rates.METHODSThe Nationwide Inpatient Sample (NIS) was used (1998–2009). Patients were included in a spinal analysis cohort for instrumented spine surgery involving the cervical spine (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 81.31–81.33, 81.01–81.03, 84.61–84.62, and 84.66) or lumbar spine (codes 81.04–81.08, 81.34–81.38, 84.64–84.65, and 84.68). A cranial analysis cohort consisted of patients receiving a parenchymal excision or lobectomy operation (codes 01.53 and 01.59). Surgeon specialization was measured using unique surgeon identifiers in the NIS and defined as the proportion of a surgeon’s total practice dedicated to cranial or spinal cases.RESULTSA total of 46,029 and 231,875 patients were identified in the cranial and spinal analysis cohorts, respectively. On multivariate analysis in the cranial analysis cohort (after controlling for overall surgeon volume, patient demographic data/comorbidities, hospital characteristics, and admitting source), each percentage-point increase in a surgeon’s cranial specialization (that is, the proportion of cranial cases) was associated with a 0.0060 reduction in the log odds of patient mortality (95% CI 0.0034–0.0086) and a 0.0042 reduction in the log odds of morbidity (95% CI 0.0032–0.0052). This resulted in a 15% difference in the predicted probability of mortality for neurosurgeons at the 75th versus the 25th percentile of cranial specialization. In the spinal analysis cohort, each percentage-point increase in a surgeon’s spinal specialization was associated with a 0.0122 reduction in the log odds of mortality (95% CI 0.0074–0.0170) and a 0.0058 reduction in the log odds of morbidity (95% CI 0.0049–0.0067). This resulted in a 26.8% difference in the predicted probability of mortality for neurosurgeons at the 75th versus the 25th percentile of spinal specialization.CONCLUSIONSFor both spinal and cranial surgery patient cohorts derived from the NIS database, increased surgeon specialization was significantly and independently associated with improved mortality and morbidity rates, even after controlling for overall case volume.
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Affiliation(s)
- Brandon A. McCutcheon
- 1Department of Neurosurgery, University of California, San Diego, La Jolla, California
- 2Department of Neurologic Surgery, Mayo Clinic and Mayo Clinic Foundation, Rochester, Minnesota
| | - Brian R. Hirshman
- 1Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Brandon C. Gabel
- 1Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Michael W. Heffner
- 1Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Logan P. Marcus
- 1Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Tyler S. Cole
- 3Barrow Neurological Institute, Phoenix, Arizona; and
| | - Clark C. Chen
- 1Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - David C. Chang
- 1Department of Neurosurgery, University of California, San Diego, La Jolla, California
- 4Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Bob S. Carter
- 1Department of Neurosurgery, University of California, San Diego, La Jolla, California
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Mortality Among Veterans and Non-veterans: Does Type of Health Care Coverage Matter? POPULATION RESEARCH AND POLICY REVIEW 2018. [DOI: 10.1007/s11113-018-9468-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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The Risks of Hepatitis C in Association With Cervical Spinal Surgery: Analysis of Radiculopathy and Myelopathy Patients. Clin Spine Surg 2018; 31:86-92. [PMID: 29293101 DOI: 10.1097/bsd.0000000000000606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE To investigate rates of in-hospital postsurgical complications among hepatitis C-infected patients after cervical spinal surgery in comparison with uninfected patients and determine independent risk factors. SUMMARY OF BACKGROUND DATA Studying hepatitis C virus (HCV) as a possible risk factor for cervical spine postoperative complications is prudent, given the high prevalence of cervical spondylosis and HCV in older patients. Spine literature is limited with respect to the impact of chronic HCV upon complications after surgery. MATERIALS AND METHODS Patients who underwent cervical spine surgery for cervical radiculopathy (CR) or cervical myelopathy (CM) from 2005 to 2013 were retrospectively reviewed using the Nationwide Inpatient Sample database. Patients were divided into CR and CM groups, with comparative subgroup analysis of HCV and no-HCV patients. Univariate analysis compared demographics and complications. Binary logistic stepwise regression modeling identified any independent outcome predictors (covariates: age, sex, Deyo score, and surgical approach). RESULTS In total, 227,310 patients (HCV: n=2542; no-HCV: n=224,764) were included. From 2005 to 2013, HCV infection prevalence among all cervical spinal fusion cases increased from 0.8% to 1.2%. HCV patients were more likely to be African American or Hispanic and have Medicare and/or Medicaid (all P<0.001). Overall complication rates among HCV patients with CR or CM increased, specifically related to device (CR: 3.1% vs. 1.9%; CM: 2.9% vs. 1.3%), hematoma/seroma (CR: 1.1% vs. 0.4%; CM: 1.8% vs. 0.8%), and sepsis (CR: 0.4% vs. 0.1%; CM: 1.1% vs. 0.5%) (all P≤0.001). Among CR and CM patients, HCV significantly predicted increased complication rates [odds ratio (OR): 1.268; OR: 1.194], hospital stay (OR: 1.738; OR: 1.861), and hospital charges (OR: 1.516; OR: 1.732; all P≤0.044). CONCLUSIONS HCV patients undergoing cervical spinal surgery were found to have increased risks of postoperative complications and increased risk associated with surgical approach. These findings should augment preoperative risk stratification and counseling for HCV patients and their spine surgeons. LEVEL OF EVIDENCE Level III.
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Charles EJ, Johnston LE, Herbert MA, Mehaffey JH, Yount KW, Likosky DS, Theurer PF, Fonner CE, Rich JB, Speir AM, Ailawadi G, Prager RL, Kron IL. Impact of Medicaid Expansion on Cardiac Surgery Volume and Outcomes. Ann Thorac Surg 2017; 104:1251-1258. [PMID: 28552372 PMCID: PMC5610068 DOI: 10.1016/j.athoracsur.2017.03.079] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/21/2017] [Accepted: 03/27/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Thirty-one states approved Medicaid expansion after implementation of the Affordable Care Act. The objective of this study was to evaluate the effect of Medicaid expansion on cardiac surgery volume and outcomes comparing one state that expanded to one that did not. METHODS Data from the Virginia (nonexpansion state) Cardiac Services Quality Initiative and the Michigan (expanded Medicaid, April 2014) Society of Thoracic and Cardiovascular Surgeons Quality Collaborative were analyzed to identify uninsured and Medicaid patients undergoing coronary bypass graft or valve operations, or both. Demographics, operative details, predicted risk scores, and morbidity and mortality rates, stratified by state and compared across era (preexpansion: 18 months before vs postexpansion: 18 months after), were analyzed. RESULTS In Virginia, there were no differences in volume between eras, whereas in Michigan, there was a significant increase in Medicaid volume (54.4% [558 of 1,026] vs 84.1% [954 of 1,135], p < 0.001) and a corresponding decrease in uninsured volume. In Virginia Medicaid patients, there were no differences in predicted risk of morbidity or mortality or postoperative major morbidities. In Michigan Medicaid patients, a significant decrease in predicted risk of morbidity or mortality (11.9% [8.1% to 20.0%] vs 11.1% [7.7% to 17.9%], p = 0.02) and morbidities (18.3% [102 of 558] vs 13.2% [126 of 954], p = 0.008) was identified. Postexpansion was associated with a decreased risk-adjusted rate of major morbidity (odds ratio, 0.69; 95% confidence interval, 0.51 to 0.91; p = 0.01) in Michigan Medicaid patients. CONCLUSIONS Medicaid expansion was associated with fewer uninsured cardiac surgery patients and improved predicted risk scores and morbidity rates. In addition to improving health care financing, Medicaid expansion may positively affect patient care and outcomes.
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Affiliation(s)
- Eric J Charles
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Virginia Cardiac Services Quality Initiative, Falls Church, Virginia
| | - Lily E Johnston
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Virginia Cardiac Services Quality Initiative, Falls Church, Virginia
| | - Morley A Herbert
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan
| | - J Hunter Mehaffey
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Virginia Cardiac Services Quality Initiative, Falls Church, Virginia
| | - Kenan W Yount
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Virginia Cardiac Services Quality Initiative, Falls Church, Virginia
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan
| | - Patricia F Theurer
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan
| | - Clifford E Fonner
- Virginia Cardiac Services Quality Initiative, Falls Church, Virginia
| | - Jeffrey B Rich
- Virginia Cardiac Services Quality Initiative, Falls Church, Virginia
| | - Alan M Speir
- Virginia Cardiac Services Quality Initiative, Falls Church, Virginia; Department of Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Gorav Ailawadi
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Virginia Cardiac Services Quality Initiative, Falls Church, Virginia
| | - Richard L Prager
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan
| | - Irving L Kron
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Virginia Cardiac Services Quality Initiative, Falls Church, Virginia.
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Tanenbaum JE, Knapik DM, Wera GD, Fitzgerald SJ. National Incidence of Patient Safety Indicators in the Total Hip Arthroplasty Population. J Arthroplasty 2017; 32:2669-2675. [PMID: 28511946 PMCID: PMC5572751 DOI: 10.1016/j.arth.2017.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 02/24/2017] [Accepted: 04/03/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services use the incidence of patient safety indicators (PSIs) to determine health care value and hospital reimbursement. The national incidence of PSI has not been quantified in the total hip arthroplasty (THA) population, and it is unknown if patient insurance status is associated with PSI incidence after THA. METHODS All patients in the Nationwide Inpatient Sample (NIS) who underwent THA in 2013 were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The incidence of PSI was determined using the International Classification of Diseases, Ninth Revision, diagnosis code algorithms published by the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality. The association of insurance status and the incidence of PSI during the inpatient episode was determined by comparing privately insured and Medicare patients with Medicaid/self-pay patients using a logistic regression model that controlled for patient demographics, patient comorbidities, and hospital characteristics. RESULTS In 2013, the NIS included 68,644 hospitalizations with primary THA performed during the inpatient episode. During this period, 429 surgically relevant PSI were recorded in the NIS. The estimated national incidence rate of PSI after primary THA was 0.63%. In our secondary analysis, the privately insured cohort had significantly lower odds of experiencing one or more PSIs relative to the Medicaid/self-pay cohort (odds ratio, 0.47; 95% confidence interval, 0.29-0.76). CONCLUSION The national incidence of PSI among THA patients is relatively low. However, primary insurance status is associated with the incidence of one or more PSIs after THA. As value-based payment becomes more widely adopted in the United States, quality benchmarks and penalty thresholds need to account for these differences in risk-adjustment models to promote and maintain access to care in the underinsured population.
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Affiliation(s)
- Joseph E. Tanenbaum
- Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA,Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio, USA,Corresponding Author: Joseph Tanenbaum, Department of Orthopedic Surgery, University Hospital Case Medical Center, 11100 Euclid Avenue, Cleveland, Ohio 44106, Tel: 518-369-1053,
| | - Derrick M. Knapik
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio, USA
| | - Glenn D. Wera
- Department of Orthopedic Surgery, Metro Health Medical Center, Cleveland, Ohio, USA
| | - Steven J. Fitzgerald
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio, USA
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Abstract
BACKGROUND Bariatric surgery leads to dramatic weight loss and improved overall health, which may affect insurance status for certain patients. Traditional Medicaid provides coverage for children, pregnant women, and disabled adults, while expanded Medicaid provides insurance coverage to all adults with incomes up to 138% of the federal poverty level. We hypothesized that successful bariatric surgery would lead to improved health status but an unintended loss of Medicaid coverage. METHODS All patients who underwent bariatric surgery at a single institution in a non-expansion state from 1985 through 2015 were identified using a prospectively collected database. Univariate and multivariate analyses were used to identify differences in patients who lost Medicaid coverage after bariatric surgery. RESULTS Over the 30-year study period, 3487 patients underwent bariatric surgery, with 373 (10.7%) having Medicaid coverage at the time of surgery. This cohort of patients had a median age of 37 years and a preoperative Body Mass Index (BMI) of 54 kg/m2. At one-year follow-up, 155 (41.6%) patients lost Medicaid coverage, of which 76 (49.0%) had no coverage. The preoperative prevalence of diabetes (32.3 vs. 44.0%, p = 0.02), age (36 vs. 38 years, p = 0.01), and BMI (53 vs. 55 kg/m2, p = 0.04) were significantly lower in patients who no longer qualified for Medicaid after bariatric surgery. Multivariate regression demonstrated that for every 10 point increase in BMI (OR 0.755, p = 0.01), a patient was 25% less likely to lose their coverage at one year. CONCLUSIONS Successful surgery in a state not expanding Medicaid resulted in over 40% of patients losing Medicaid coverage postoperatively, with half of those patients returning for follow-up with no insurance coverage at all. This barrier to care has major implications in patients undergoing bariatric surgery, which requires life-long follow-up and nutrition screening.
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Armenia SJ, Pentakota SR, Merchant AM. Socioeconomic factors and mortality in emergency general surgery: trends over a 20-year period. J Surg Res 2017; 212:178-186. [PMID: 28550905 DOI: 10.1016/j.jss.2017.01.015] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 11/26/2016] [Accepted: 01/18/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Socioeconomic factors such as race, insurance, and income quartiles have been identified as independent risk factors in emergency general surgery (EGS), but this impact has not been studied over time. We sought to identify trends in disparities in EGS-related operative mortality over a 20-y period. METHODS The National Inpatient Sample was used to identify patient encounters coded for EGS in 1993, 2003, and 2013. Logistic regression models were used to examine the adjusted relationship between race, primary payer status, and median income quartiles and in-hospital mortality after adjusting for patients' age, gender, Elixhauser comorbidity score, and hospital region, size, and location-cum-teaching status. RESULTS We identified 391,040 patient encounters. In 1993, Black race was associated with higher odds of in-hospital mortality (odds ratio [95% confidence interval]: 1.35 [1.20-1.53]) than White race, although this difference dissipated in subsequent years. Medicare, Medicaid, and underinsured patients had a higher odds of mortality than those with private insurance for the entire 20-y period; only the disparity in the underinsured decreased over time (1993, 1.63 [1.35-1.98]; 2013, 1.41 [1.20-1.67]). In 2003 (1.23 [1.10-1.38]) and 2013 (1.23 [1.11-1.37]), patients from the lowest income quartile were more likely to die after EGS than patients from the highest income quartile. CONCLUSIONS Socioeconomic disparities in EGS-related operative morality followed inconsistent trends. Over time, while gaps in in-hospital mortality among Blacks and Whites have narrowed, disparities among patients belonging to lowest income quartile have worsened. Medicare and Medicaid beneficiaries continued to experience higher odds of in-hospital mortality relative to those with private insurance.
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Affiliation(s)
- Sarah J Armenia
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Sri Ram Pentakota
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Aziz M Merchant
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.
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Stagnant Physical Therapy Referral Rates Alongside Rising Opioid Prescription Rates in Patients With Low Back Pain in the United States 1997-2010. Spine (Phila Pa 1976) 2017; 42:670-674. [PMID: 28441685 PMCID: PMC9853341 DOI: 10.1097/brs.0000000000001875] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A cross-sectional observational study utilizing the National Ambulatory and National Hospital Ambulatory Medical Care Surveys between 1997 and 2010. OBJECTIVE The aim of this study was to characterize national physical therapy (PT) referral trends during primary care provider (PCP) visits in the United States. SUMMARY OF BACKGROUND DATA Despite guidelines recommending PT for the initial management of low back pain (LBP), national PT referral rates remain low. METHODS Race, ethnicity, age, payer type, and PT referral rates were collected for patients aged 16 to 90 years who were visiting their PCPs. Associations among demographic variables and PT referral were determined using logistic regression. RESULTS Between 1997 and 2010, we estimated 170 million visits for LBP leading to 17.1 million PT referrals. Average proportion of PCP visits associated with PT referrals remained stable at about 10.1% [odds ratio (OR) 1.00, 95% confidence interval (95% CI) 0.96-1.04)], despite our prior finding of increasing number of visits associated with opioid prescriptions in the same timeframe.Lower PT referral rates were observed among visits by patients who were insured by Medicaid (OR 0.48, 95% CI 0.33-0.69) and Medicare (OR 0.50, 95% CI 0.35-0.72). Furthermore, visits not associated with PT referrals were more likely to be associated with opioid prescriptions (OR 1.69, 95% CI 1.22-2.35). CONCLUSION Although therapies delivered by PTs are promoted as a first-line treatment for LBP, PT referral rates remain low. There also exist disparately lower referral rates in populations with more restrictive health plans and simultaneous opioid prescription. Our findings provide a broad overview to PT prescription trend and isolate concerning associations requiring further explorations. LEVEL OF EVIDENCE 3.
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Mehdi SK, Tanenbaum JE, Alentado VJ, Miller JA, Lubelski D, Benzel EC, Mroz TE. Disparities in reportable quality metrics by insurance status in the primary spine neoplasm population. Spine J 2017; 17:244-251. [PMID: 27664341 PMCID: PMC5493960 DOI: 10.1016/j.spinee.2016.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 08/22/2016] [Accepted: 09/12/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The Centers for Medicare and Medicaid Services (CMS) defines "adverse quality events" as the incidence of certain complications such as postsurgical hematoma or iatrogenic pneumothorax during an inpatient stay. Patient safety indicators (PSI) are a means to measure the incidence of these adverse events. When adverse events occur, reimbursement to the hospital decreases. The incidence of adverse quality events among patients hospitalized for primary spinal neoplasms is unknown. Similarly, it is unclear what the impact of insurance status is on adverse care quality among this patient population. PURPOSE We aimed to determine the incidence of PSI among patients admitted with primary spinal neoplasms, and to determine the association between insurance status and the incidence of PSI in this population. STUDY DESIGN This is a retrospective cohort study. PATIENT SAMPLE We included all patients, 18 years and older, in the Nationwide Inpatient Sample (NIS) who were hospitalized for primary spine neoplasms from 1998 to 2011. OUTCOME MEASURES Incidence of PSI from 1998 to 2011 served as outcome variable. METHODS The NIS was queried for all hospitalizations with a diagnosis of primary spinal neoplasm during the inpatient episode from 1998 to 2011. Incidence of PSI was determined using publicly available lists of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Logistic regression models were used to determine the effect of primary payer status on PSI incidence. All comparisons were made between privately insured patients and Medicaid or self-pay patients. RESULTS We identified 6,095 hospitalizations in which a primary spinal neoplasm was recorded during the inpatient episode. We excluded patients younger than 18 years and those with "other" or "missing" primary insurance status, leaving 5,880 patients for analysis. After adjusting for patient demographics and hospital characteristics, Medicaid or self-pay patients had significantly greater odds of experiencing one or more PSI (odds ratio [OR] 1.81 95% confidence interval [CI] 1.11-2.95) relative to privately insured patients. CONCLUSIONS Among patients hospitalized for primary spinal neoplasms, primary payer status predicts the incidence of PSI, an indicator of adverse health-care quality used to determine hospital reimbursement by the CMS. As reimbursement continues to be intertwined with reportable quality metrics, identifying vulnerable populations is critical to improving patient care.
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Affiliation(s)
- Syed K Mehdi
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 10900 Euclid Ave., Cleveland, OH 44106, USA.
| | - Joseph E Tanenbaum
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 10900 Euclid Ave., Cleveland, OH 44106, USA; Department of Epidemiology and Biostatistics, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106, USA
| | - Vincent J Alentado
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 10900 Euclid Ave., Cleveland, OH 44106, USA
| | - Jacob A Miller
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave., NA41, Cleveland, OH 44195, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 855 N Wolfe St, Baltimore, MD 21205, USA
| | - Edward C Benzel
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave., NA41, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave., S-80, Cleveland, OH 44195, USA
| | - Thomas E Mroz
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave., NA41, Cleveland, OH 44195, USA; Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave., A41, Cleveland, OH 44195, USA
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Tanenbaum JE, Miller JA, Alentado VJ, Lubelski D, Rosenbaum BP, Benzel EC, Mroz TE. Insurance status and reportable quality metrics in the cervical spine fusion population. Spine J 2017; 17:62-69. [PMID: 27497887 PMCID: PMC5493958 DOI: 10.1016/j.spinee.2016.08.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 06/14/2016] [Accepted: 08/02/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The incidence of adverse care quality events among patients undergoing cervical fusion surgery is unknown using the definition of care quality employed by the Centers for Medicare and Medicaid Services (CMS). The effect of insurance status on the incidence of these adverse quality events is also unknown. PURPOSE This study determined the incidence of hospital-acquired conditions (HAC) and patient safety indicators (PSI) in patients with cervical spine fusion and analyzed the association between primary payer status and these adverse events. STUDY DESIGN This is a retrospective cohort design. PATIENT SAMPLE All patients in the Nationwide Inpatient Sample (NIS) aged 18 and older who underwent cervical spine fusion from 1998 to 2011 were included. OUTCOME MEASURES Incidence of HAC and PSI from 1998 to 2011 served as outcome variables. METHODS We queried the NIS for all hospitalizations that included a cervical fusion during the inpatient episode from 1998 to 2011. All comparisons were made between privately insured patients and Medicaid or self-pay patients because Medicare enrollment is confounded with age. Incidence of nontraumatic HAC and PSI was determined using publicly available lists of International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. We built logistic regression models to determine the effect of primary payer status on PSI and nontraumatic HAC. RESULTS We identified 419,424 hospitalizations with cervical fusion performed during an inpatient episode. The estimated national incidences of nontraumatic HAC and PSI were 0.35% and 1.6%, respectively. After adjusting for patient demographics and hospital characteristics, Medicaid or self-pay patients had significantly greater odds of experiencing one or more HAC (odds ratio [OR] 1.51 95% conflict of interest [CI] 1.23-1.84) or PSI (OR 1.52 95% CI 1.37-1.70) than the privately insured cohort. CONCLUSIONS Among patients undergoing inpatient cervical fusion, primary payer status predicts PSI and HAC (both indicators of adverse health-care quality used to determine hospital reimbursement by CMS). As the US health-care system transitions to a value-based payment model, the cause of these disparities must be studied to improve the quality of care delivered to vulnerable patient populations.
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Affiliation(s)
- Joseph E. Tanenbaum
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA,Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio, USA,Corresponding Author: Joseph Tanenbaum, Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Avenue, S-80, Cleveland, Ohio 44195, Tel: 518-369-1053,
| | - Jacob A. Miller
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vincent J. Alentado
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benjamin P. Rosenbaum
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA,Anchorage Neurosurgical Associates, Inc., Anchorage, AK
| | - Edward C. Benzel
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Thomas E. Mroz
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA,Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Wagenaar AE, Tashiro J, Sola JE, Ekwenna O, Tekin A, Perez EA. Pediatric liver transplantation: predictors of survival and resource utilization. Pediatr Surg Int 2016; 32:439-49. [PMID: 27001031 DOI: 10.1007/s00383-016-3881-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE We sought to identify factors associated with increased resource utilization and in-hospital mortality for pediatric liver transplantation (LT). METHODS Kids' Inpatient Database (1997-2009) was used to identify cases of LT in patients <20 years old. RESULTS Overall, 2905 cases were identified, with an in-hospital survival of 91 %. LT was performed most frequently in < 5 year olds (61 %), females (51 %), and Caucasians (56 %). LT was performed at urban teaching hospitals (97 %) and facilities with children's units (51 %). Indications included pathologic conditions of the biliary tract (44 %) and inborn errors of metabolism (34 %), though unspecified end stage liver disease was the most common (75 %). Logistic regression found higher mortality in children undergoing LT for malignant conditions (odds ratio: 4.8) and acute hepatic failure (OR 3.4). Cases complicated by renal failure (OR 7.7) and complications of LT (OR 2.7) had higher mortality rates. Resource utilization increased for children with renal failure and those with hemorrhage as a complication of LT, p < 0.05. CONCLUSION Hospital survival is predicted by indication and complications associated with LT. Resource utilization increased with renal failure and complications related to LT. Admission length was sensitive to payer status, hospital characteristics, and UNOS region, whereas total costs were unaffected by payer status or hospital type.
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Affiliation(s)
- Amy E Wagenaar
- Division of Pediatric Surgery, DeWitt-Daughtry Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Suite 450, Miami, FL, 33136, USA
| | - Jun Tashiro
- Division of Pediatric Surgery, DeWitt-Daughtry Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Suite 450, Miami, FL, 33136, USA
| | - Juan E Sola
- Division of Pediatric Surgery, DeWitt-Daughtry Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Suite 450, Miami, FL, 33136, USA
| | - Obi Ekwenna
- Miami Transplant Institute, Jackson Memorial Hospital, Miami, FL, USA
| | - Akin Tekin
- Miami Transplant Institute, Jackson Memorial Hospital, Miami, FL, USA
| | - Eduardo A Perez
- Division of Pediatric Surgery, DeWitt-Daughtry Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Suite 450, Miami, FL, 33136, USA.
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Ahmed A, Harland KK, Hoffman B, Liao J, Choi K, Skeete D, Denning G. Not Just an Urban Phenomenon: Uninsured Rural Trauma Patients at Increased Risk for Mortality. West J Emerg Med 2015; 16:632-41. [PMID: 26587084 PMCID: PMC4644028 DOI: 10.5811/westjem.2015.7.27351] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 07/27/2015] [Accepted: 07/30/2015] [Indexed: 12/04/2022] Open
Abstract
Introduction National studies of largely urban populations showed increased risk of traumatic death among uninsured patients, as compared to those insured. No similar studies have been done for major trauma centers serving rural states. Methods We performed retrospective analyses using trauma registry records from adult, non-burn patients admitted to a single American College of Surgeons-certified Level 1 trauma center in a rural state (2003–2010, n=13,680) and National Trauma Data Bank (NTDB) registry records (2002–2008, n=380,182). Risk of traumatic death was estimated using multivariable logistic regression analysis. Results We found that 9% of trauma center patients and 27% of NTDB patients were uninsured. Overall mortality was similar for both (~4.5%). After controlling for covariates, uninsured trauma center patients were almost five times more likely to die and uninsured NTDB patients were 75% more likely to die than commercially insured patients. The risk of death among Medicaid patients was not significantly different from the commercially insured for either dataset. Conclusion Our results suggest that even with an inclusive statewide trauma system and an emergency department that does not triage by payer status, uninsured patients presenting to the trauma center were at increased risk of traumatic death relative to patients with commercial insurance.
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Affiliation(s)
- Azeemuddin Ahmed
- University of Iowa, Department of Emergency Medicine, Iowa City, Iowa
| | - Karisa K Harland
- University of Iowa, Department of Emergency Medicine, Iowa City, Iowa
| | - Bryce Hoffman
- University of Iowa, Department of Emergency Medicine, Iowa City, Iowa
| | - Junlin Liao
- University of Iowa, Department of Surgery, Iowa City, Iowa
| | - Kent Choi
- University of Iowa, Department of Surgery, Iowa City, Iowa
| | - Dionne Skeete
- University of Iowa, Department of Surgery, Iowa City, Iowa
| | - Gerene Denning
- University of Iowa, Department of Emergency Medicine, Iowa City, Iowa
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Costs of hepato-pancreato-biliary surgery and readmissions in privately insured US patients. J Surg Res 2015; 199:478-86. [PMID: 26026853 DOI: 10.1016/j.jss.2015.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/19/2015] [Accepted: 05/01/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgical costs are influenced by perioperative care, readmissions, and further therapies. We aimed to characterize costs in hepato-pancreato-biliary surgery in the United States. METHODS The MarketScan database (2008-2010) was used to identify privately insured patients undergoing pancreatectomy (n = 2254) or hepatectomy (n = 1702). Costs associated with the index surgery, readmissions, and total short-term costs were assessed from a third party payer perspective using generalized linear regression models. RESULTS Mean total costs of pancreatectomy and hepatectomy were $107,600 (95% confidence interval [CI], 101,200-114,000) and $81,300 (95% CI, 77,600-85,000), respectively, with corresponding surgical costs of 69.2% and 60.9%. Ninety-day readmission costs were $36,200 (95% CI, 32,000-40,400) and $34,100 (95% CI, 28,100-40,100), respectively. In multivariate analysis, readmissions were associated with an almost two-fold increase in total costs in both pancreatectomy (cost ratio = 1.98; P < 0.001) and hepatectomy (cost ratio = 1.92; P < 0.001). CONCLUSIONS Hepato-pancreato-biliary surgery is associated with significant economic burden in the privately insured population. Substantial costs are incurred beyond the index surgical admission, with readmissions representing a major source of potentially preventable health care spending. Sustained efforts in defining high-risk populations and decreasing the burden of postoperative complications through a combination of prevention and improved outpatient management offer promising strategies to reduce readmissions and control costs.
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A Multi-institutional Analysis of Insurance Status as a Predictor of Morbidity Following Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2014; 2:e255. [PMID: 25506538 PMCID: PMC4255898 DOI: 10.1097/gox.0000000000000207] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 09/04/2014] [Indexed: 11/26/2022]
Abstract
Background: Although recent literature suggests that patients with Medicaid and Medicare are more likely than those with private insurance to experience complications following a variety of procedures, there has been limited evaluation of insurance-based disparities in reconstructive surgery outcomes. Using a large, multi-institutional database, we sought to evaluate the potential impact of insurance status on complications following breast reconstruction. Methods: We identified all breast reconstructive cases in the 2008 to 2011 Tracking Operations and Outcomes for Plastic Surgeons clinical registry. Propensity scores were calculated for each case, and insurance cohorts were matched with regard to demographic and clinical characteristics. Outcomes of interest included 15 medical and 13 surgical complications. Results: Propensity-score matching yielded 493 matched patients for evaluation of Medicaid and 670 matched patients for evaluation of Medicare. Overall complication rates did not significantly differ between patients with Medicaid or Medicare and those with private insurance (P = 0.167 and P = 0.861, respectively). Risk-adjusted multivariate regressions corroborated this finding, demonstrating that Medicaid and Medicare insurance status does not independently predict surgical site infection, seroma, hematoma, explantation, or wound dehiscence (all P > 0.05). Medicaid insurance status significantly predicted flap failure (odds ratio = 3.315, P = 0.027). Conclusions: This study is the first to investigate the differential effects of payer status on outcomes following breast reconstruction. Our results suggest that Medicaid and Medicare insurance status does not independently predict increased overall complication rates following breast reconstruction. This finding underscores the commitment of the plastic surgery community to providing consistent care for patients, irrespective of insurance status.
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Andersen ND, Brennan JM, Zhao Y, Williams JB, Williams ML, Smith PK, Scarborough JE, Hughes GC. Insurance status is associated with acuity of presentation and outcomes for thoracic aortic operations. Circ Cardiovasc Qual Outcomes 2014; 7:398-406. [PMID: 24714600 DOI: 10.1161/circoutcomes.113.000593] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nonelective procedure status is the greatest risk factor for postoperative morbidity and mortality in patients undergoing thoracic aortic operations. We hypothesized that uninsured patients were more likely to require nonelective thoracic aortic operation due to decreased access to preventative care and elective surgical services. METHODS AND RESULTS An observational study of the Society of Thoracic Surgeons Database identified 51 282 patients who underwent thoracic aortic surgery between 2007 and 2011 at 940 North American centers. Patients were stratified by insurance status (private insurance, Medicare, Medicaid, other insurance, or uninsured) as well as age <65 or ≥65 years to account for differences in Medicare eligibility. The need for nonelective thoracic aortic operation was highest for uninsured patients (71.7%) and lowest for privately insured patients (36.6%). The adjusted risks of nonelective operation were increased for uninsured patients (adjusted risk ratio, 1.77; 95% confidence interval, 1.70-1.83 for age <65 years; adjusted risk ratio, 1.46; 95% confidence interval, 1.29-1.62 for age ≥65 years) as well as Medicaid patients aged <65 years (adjusted risk ratio, 1.18; 95% confidence interval, 1.10-1.26) when compared with patients with private insurance. The adjusted risks of major morbidity or mortality were further increased for all patients aged <65 years without private insurance (adjusted risk ratios between 1.13 and 1.27). CONCLUSIONS Insurance status was associated with acuity of presentation and major morbidity and mortality for thoracic aortic operations. Efforts to reduce insurance-based disparities in the care of patients with thoracic aortic disease seem warranted and may reduce the incidence of aortic emergencies and improve outcomes after thoracic aortic surgery.
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Affiliation(s)
- Nicholas D Andersen
- From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.)
| | - J Matthew Brennan
- From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.)
| | - Yue Zhao
- From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.)
| | - Judson B Williams
- From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.)
| | - Matthew L Williams
- From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.)
| | - Peter K Smith
- From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.)
| | - John E Scarborough
- From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.)
| | - G Chad Hughes
- From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.).
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Insurance status predicts acuity of thoracic aortic operations. J Thorac Cardiovasc Surg 2014; 148:2082-6. [PMID: 24725770 DOI: 10.1016/j.jtcvs.2014.03.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 02/24/2014] [Accepted: 03/12/2014] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Nonelective case status is the strongest predictor of mortality for thoracic aortic operations. We hypothesized that underinsured patients were more likely to require nonelective thoracic aortic surgery because of reduced access to preventative cardiovascular care and elective surgical services. METHODS Between June 2005 and August 2011, 826 patients were admitted to a single aortic referral center and underwent 1 or more thoracic aortic operations. Patients with private insurance or Medicare (insured group, n=736; 89%) were compared with those with Medicaid or no insurance (underinsured group, n=90; 11%). RESULTS The proportion of patients requiring nonelective surgery was higher for underinsured than insured patients (56% vs 26%, P<.0001). Multivariable analysis revealed underinsurance to be the strongest independent predictor of nonelective case status (odds ratio [OR], 2.67; P<.0001). Preoperative use of lipid-lowering medications (OR, 0.63; P<.009) or a history of aortic surgery (OR, 0.48; P<.001) was associated with a decreased risk of nonelective operation. However, after adjustment for differences in preoperative characteristics and case status, underinsurance did not confer an increased risk of procedural morbidity or mortality (adjusted OR, 0.94; P=.83) or late death (adjusted hazard ratio, 0.83, P=.58) when compared with insured patients. CONCLUSIONS Underinsured patients were at the greatest risk of requiring nonelective thoracic aortic operation, possibly because of decreased use of lipid-lowering therapies and aortic surveillance. These data imply that greater access to preventative cardiovascular care may reduce the need for nonelective thoracic aortic surgery and lead to improved survival from thoracic aortic disease.
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Polanco A, Breglio AM, Itagaki S, Goldstone AB, Chikwe J. Does payer status impact clinical outcomes after cardiac surgery? A propensity analysis. Heart Surg Forum 2013; 15:E262-7. [PMID: 23092662 DOI: 10.1532/hsf98.20111163] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Medicaid patients bear proportionately greater financial responsibility for the cost of outpatient care and medication than non-Medicaid patients. We hypothesized that this difference in provision of continuing care would be associated with adverse clinical outcomes after cardiac surgery. MATERIALS AND METHODS In a retrospective cohort analysis, 5056 consecutive adult patients undergoing cardiac surgery at a single institution between 2005 and 2010 were divided according to payer status. Propensity scores were calculated using 16 preoperative and demographic variables for each patient, and 461 1:1 propensity score-matched pairs were analyzed. Patient socioeconomic position was determined using aggregate data derived from zip codes. The main outcome measures were early mortality, postoperative complications, and patient survival. RESULTS In multivariate analysis, Medicaid was found to be an independent predictor of worse survival after cardiac surgery (hazard ratio [HR], 2.1; 95% confidence interval [CI], 1.2-3.7; P = .01). No significant difference was observed in operative mortality in the 2 groups. After propensity score matching and controlling for socioeconomic position, the only independent predictors of worse midterm survival were an ejection fraction = 30% (HR, 1.7; 95% CI, 1.1-2.7; P = .02) and a higher logistic EuroSCORE (HR, 1.03; 95% CI, 1.0-1.1; P = .02). CONCLUSIONS Comorbidity and lower socioeconomic status appear to be more important predictors of late mortality after cardiac surgery than payer status, which does not have a significant impact on survival.
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Affiliation(s)
- Antonio Polanco
- Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY, USA
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Abstract
BACKGROUND Medicaid populations have been shown to have inferior surgical outcomes, but less is known about their access to advanced surgical procedures. OBJECTIVE The aim of this study was to evaluate if patients with Medicaid and ulcerative colitis who presented for subtotal colectomy would have reduced access to the laparoscopic approach in comparison with a similar population with private insurance. DESIGN/SETTINGS/PATIENTS Using the Nationwide Inpatient Sample database from 2008 to 2010, we identified all patients who underwent subtotal colectomy for ulcerative colitis. The χ test and multivariable logistic regression were used to identify predictors for laparoscopic subtotal colectomy for ulcerative colitis. MAIN OUTCOME MEASURES The primary end point was the use of open or laparoscopic subtotal colectomy. Secondary end points included hospital length of stay and surgical outcomes. RESULTS We identified a total of 2589 subtotal colectomy hospitalizations for ulcerative colitis (435 with Medicaid and 2154 with private insurance). The private insurance and Medicaid groups did not have significantly different mean age, sex, or Charlson scores (p > 0.05). Although 43% of the private insurance cohort received laparoscopic subtotal colectomy during their hospitalization, only 23% of the Medicaid population received equivalent care (p < 0.001). In a multivariate analysis that included age, sex, emergency status, hospital location, hospital size, teaching status, income, and Charlson score, urban teaching hospital status (p < 0.01), emergency status (p = 0.045), age <40 (p < 0.01), northeast location (p = 0.01), and private insurance status (p < 0.01) were independent predictors of the laparoscopic approach. LIMITATIONS Administrative data have the potential for unrecognized miscoding or incomplete risk adjustment. Disease severity is not accounted for in the Nationwide Inpatient Sample database. CONCLUSION Medicaid payer status was associated with reduced use of laparoscopic subtotal colectomy for ulcerative colitis. Although this finding may be due in part to physician preference or patient characteristics, health system factors appear to contribute to selection of the surgical approach.
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Mills AM, Holena DN, Kallan MJ, Carr BG, Reinke CE, Kelz RR. Effect of insurance status on patients admitted for acute diverticulitis. Colorectal Dis 2013; 15:613-20. [PMID: 23078007 DOI: 10.1111/codi.12066] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 08/21/2012] [Indexed: 02/08/2023]
Abstract
AIM The study aimed to evaluate the relationship between insurance status and the management and outcome of acute diverticulitis in a nationally representative sample. METHOD A retrospective cohort analysis of a nationally representative sample of 1 031 665 hospital discharges of patients admitted for acute diverticulitis in the 2006-2009 Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project data set. The main outcome measures included state at presentation (complicated/uncomplicated), management (medical/surgical), time to surgical intervention, type of operation and inpatient death. RESULTS In total, 207 838 discharges were identified (including 37.0% with private insurance, 49.3% in Medicare, 5.6% in Medicaid and 5.8% uninsured) representing 1 031 665 total discharges nationally. Medicare patients were more likely to present with complicated diverticulitis compared with private insurance patients (23.8% vs 15.1%). Time to surgical intervention differed by insurance status. After adjusting for patient, hospital and treatment factors, Medicare patients were less likely than those with private insurance to undergo a procedure (Medicare OR = 0.86, 95% CI: 0.82-0.91), while the uninsured were more likely to undergo drainage (OR = 1.30, 95% CI: 1.16-1.46) or a colostomy only (OR = 1.70, 95% CI: 1.24-2.33). All patients without private insurance were more likely to die in hospital (Medicare OR = 1.29, 95% CI: 1.09-1.52; Medicaid OR = 1.55, 95% CI: 1.22-1.97; uninsured OR = 1.41, 95% CI: 1.07-1.87). CONCLUSION In a nationally representative sample of patients with acute diverticulitis, patient management and outcome varied significantly by insurance status, despite adjustment for potential confounders. Providers might need to heighten surveillance for complications when treating patients without private insurance to improve outcome.
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Affiliation(s)
- A M Mills
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Haider AH, Scott VK, Rehman KA, Velopulos C, Bentley JM, Cornwell EE, Al-Refaie W. Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors. J Am Coll Surg 2013; 216:482-92.e12. [PMID: 23318117 DOI: 10.1016/j.jamcollsurg.2012.11.014] [Citation(s) in RCA: 399] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Revised: 11/28/2012] [Accepted: 11/28/2012] [Indexed: 02/06/2023]
Affiliation(s)
- Adil H Haider
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Stone ML, LaPar DJ, Mulloy DP, Rasmussen SK, Kane BJ, McGahren ED, Rodgers BM. Primary payer status is significantly associated with postoperative mortality, morbidity, and hospital resource utilization in pediatric surgical patients within the United States. J Pediatr Surg 2013; 48:81-7. [PMID: 23331797 PMCID: PMC3921619 DOI: 10.1016/j.jpedsurg.2012.10.021] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 10/13/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Current healthcare reform efforts have highlighted the potential impact of insurance status on patient outcomes. The influence of primary payer status (PPS) within the pediatric surgical patient population remains unknown. The purpose of this study was to examine risk-adjusted associations between PPS and postoperative mortality, morbidity, and resource utilization in pediatric surgical patients within the United States. METHODS A weighted total of 153,333 pediatric surgical patients were evaluated using the national Kids' Inpatient Database (2003 and 2006): appendectomy, intussusception, decortication, pyloromyotomy, congenital diaphragmatic hernia repair, and colonic resection for Hirschsprung's disease. Patients were stratified according to PPS: Medicare (n=180), Medicaid (n=51,862), uninsured (n=12,539), and private insurance (n=88,753). Multivariable hierarchical regression modeling was utilized to evaluate risk-adjusted associations between PPS and outcomes. RESULTS Overall median patient age was 12 years, operations were primarily non-elective (92.4%), and appendectomies accounted for the highest proportion of cases (81.3%). After adjustment for patient, hospital, and operation-related factors, PPS was independently associated with in-hospital death (p<0.0001) and postoperative complications (p<0.02), with increased risk for Medicaid and uninsured populations. Moreover, Medicaid PPS was also associated with greater adjusted lengths of stay and total hospital charges (p<0.0001). Importantly, these results were dependent on operation type. CONCLUSIONS Primary payer status is associated with risk-adjusted postoperative mortality, morbidity, and resource utilization among pediatric surgical patients. Uninsured patients are at increased risk for postoperative mortality while Medicaid patients accrue greater morbidity, hospital lengths of stay, and total charges. These results highlight a complex interaction between socioeconomic and patient-related factors, and primary payer status should be considered in the preoperative risk stratification of pediatric patients.
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Affiliation(s)
- Matthew L. Stone
- Department of Surgery, The University of Virginia, Charlottesville, Virginia, USA
| | - Damien J. LaPar
- Department of Surgery, The University of Virginia, Charlottesville, Virginia, USA
| | - Daniel P. Mulloy
- Department of Surgery, The University of Virginia, Charlottesville, Virginia, USA
| | - Sara K. Rasmussen
- Division of Pediatric Surgery, The University of Virginia, Charlottesville, Virginia, USA
| | - Bartholomew J. Kane
- Division of Pediatric Surgery, The University of Virginia, Charlottesville, Virginia, USA
| | - Eugene D. McGahren
- Division of Pediatric Surgery, The University of Virginia, Charlottesville, Virginia, USA
| | - Bradley M. Rodgers
- Division of Pediatric Surgery, The University of Virginia, Charlottesville, Virginia, USA
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Neureuther SJ, Nagpal K, Greenbaum A, Cosgrove JM, Farkas DT. The effect of insurance status on outcomes after laparoscopic cholecystectomy. Surg Endosc 2012; 27:1761-5. [PMID: 23247740 DOI: 10.1007/s00464-012-2675-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Accepted: 10/22/2012] [Indexed: 12/25/2022]
Abstract
BACKGROUND Part of the ongoing healthcare debate is the care of uninsured patients. A common theory is that without regular outpatient care, these patients present to the hospital in the late stages of disease and therefore have worse outcomes. The purpose of this study was to evaluate any differences in outcomes after laparoscopic cholecystectomies between insured and uninsured patients. METHODS We reviewed all laparoscopic cholecystectomies (LC) done in our institution between 2006 and 2009. Patients were divided into two groups: insured patients (IP) and uninsured patients (UIP). Outcomes, including conversion and complication rates and postoperative length of stay (LOS), were collected and statistically analyzed using χ(2) and ANOVA tests. RESULTS There were 1,090 LCs done during the study period: 944 patients (86.6 %) were insured (IP) and 146 (13.4 %) were uninsured (UIP). In the IP group there were 63/944 (6.7 %) conversions and 59/944 (6.3 %) complications, while in the UIP group there were 15/146 (10.3 %) conversions and 12/146 (8.2 %) complications. There was no statistically significant difference in either of these categories. Mean (±SD) LOS was 1.73 ± 4.34 days for the IP group and 2.72 ± 4.35 days for the UIP group (p = 0.010, ANOVA). Uninsured patients were much more likely to have emergency surgery (99.3 % vs. 47.9 %, p < 0.001, χ(2)). CONCLUSIONS In our study group, being uninsured did not correlate with having a higher rate of conversion or complications. However, more uninsured patients had their surgery done emergently, and this led to significantly longer lengths of stay. Further research is necessary to study the cost impact of these findings and to see whether insuring these patients can lead to changes in their outcomes.
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Affiliation(s)
- Samantha J Neureuther
- Department of Surgery, Bronx-Lebanon Hospital Center, Albert Einstein College of Medicine, 1650 Selwyn Ave, Bronx, NY 10457, USA
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