Does Performance Vary Within the Same Hospital When Separately Examining Different Patient Subgroups?

Relative importance of individual insurance status and hospital payer mix on survival for women with cervical cancer

OBJECTIVE

To assess the relative contributions of individual insurance status and hospital payer mix (safety net status) to quality of care and survival for patients with cervical cancer.

METHODS

We used the National Cancer Database to identify patients with cervical cancer diagnosed from 2004 to 2017. Patients were classified by insurance (uninsured/Medicaid/private/Medicare/other) and hospitals were grouped into quartiles based on the proportion of uninsured/Medicaid patients (payer mix) (top quartile defined as safety-net hospital (SNHs) and lowest as Q1 hospitals). Quality-of-care was assessed by adherence to evidence-based metrics. Individual contributions of insurance status and payer mix to survival was assessed with a proportional hazards Cox model.

RESULTS

A total of 124,339 patients including 11,338 uninsured (9.1%) and 27,281 Medicaid (21.9%) recipients treated at 1156 hospitals were identified. Quality-of-care was not significantly different across hospital quartiles. Adjusting for patients' clinical/demographic characteristics, treatment at a SNH was associated with a 14% higher mortality (HR = 1.14; 95% CL, 1.08-1.20) than at Q1 hospitals. Testing for individual insurance, uninsured patients had 32% increased mortality (HR = 1.32; 95% CI,1.26-1.38) and Medicaid recipients 40% increased (HR = 1.40; 95%CI,1.35-1.44) compared to privately insured patients. Examining both payer mix and insurance, only individual insurance retained a significant impact on mortality.

CONCLUSIONS

Individual insurance may be a more important predictor of survival than site-of-care and hospital payer mix for women with cervical cancer. There is substantial variation in outcomes within hospitals based on individual insurance, regardless of hospital payer mix.

A Portrait of Socially Responsible Hospitals in Indonesia

This study’s purpose is to measure social performance in hospitals in Indonesia, specifically focusing on the tendency for hospitals to act in the process of achieving various targets with a focus on social impacts on the community, stakeholders, and the environment. Although previous studies on hospital performance exist, few focus on the aspect of social responsibility. This study offers a way to measure the current social performance of hospitals using valued reference by hospital stakeholders. This study uses descriptive analysis and ANOVA for the indicators of social performance in the context of hospitals in Indonesia. Data used are from the Indonesian Commission on Accreditation of Hospital (ICAHO). This study uses data from 752 accredited hospitals in Indonesia. Results show that there were no significant differences in social performance between the different classes of hospitals. Social performance was found to be moderate on average for all classes: A, B, C, and D. However, across different accreditation levels of hospitals in Indonesia, social performance is scored as moderate with significant differences between the groups of accreditations. The implications of the results from this study provide a practical reference point measuring social performance for accredited hospitals in Indonesia.

Explaining Racial Disparities in Surgically Treated Head and Neck Cancer

OBJECTIVES/HYPOTHESIS

To assess the causative factors that contribute to racial disparities in head and neck squamous cell carcinoma (HNSCC) and establish the role of hospital factors in racial disparities.

STUDY DESIGN

Retrospective database analysis.

METHODS

Patients with surgically treated HNSCC were identified using the National Cancer Database (2004-2014). Logistic and proportional-hazard regression models were used to characterize the factors that contribute to racial disparities. Differences in quality of care received were compared among black and white patients using previously validated metrics.

RESULTS

We identified 69,186 eligible patients. Black patients had a 48% higher mortality than white patients (HR 1.48; 95% confidence interval [CI], 1.41-1.54). Black patients had a lower mean quality score (67.6%; 95% CI, 66.8%-69.4%) compared with white patients (71.2%: 95% CI, 71.0%-71.4%) for five quality metrics. After adjusting for differences in patient, oncologic, and hospital factors we were able to explain 60% of the excess mortality for black patients. Oncologic factors at presentation accounted for 57.7% of observed mortality differences, whereas hospital characteristics and quality of care accounted for 11.5%. After adjusting for these factors, black patients still had a 19% higher mortality (HR 1.19; 95% CI, 1.14-1.24).

CONCLUSIONS

Oncologic factors at presentation are a major contributor to racial disparities in outcomes for HNSCC. Hospital factors, such as quality, volume, and safety-net status, constitute a minor factor in the mortality difference. Resolving existing disparities will require detecting head and neck cancer at an earlier stage and improving the quality of care for black patients.

LEVEL OF EVIDENCE

3. Laryngoscope, 131:1053-1059, 2021.

High-Risk Colorectal Surgery: What Are the Outcomes for Geriatric Patients?

The population is aging and more geriatric patients are undergoing surgery. The national burden and age-specific outcomes of previously defined high-risk colorectal procedures (HRCP) remain unknown. Using the 2014 National Inpatient Sample, patients were stratified into nongeriatric (NG, <65 years), younger geriatric (YG, 65–79 years), and older geriatric (OG, ≥80 years) cohorts. Cases were grouped into nonelective admissions (NA) and elective admissions (EA). Nationally representative outcomes were compared across age group and admission type. Of 215,425 patients undergoing HRCP, 47.3 per cent were ≥65 years. During NA and EA, inpatient mortality, discharge to nursing facility, and median postoperative length of stay increased with each increasing age category ( P < 0.001). Outcomes during NA were worse than EA in all age groups ( P < 0.001). For example, rates of discharge to nursing facility were 13.4 per cent NG, 39.4 per cent YG, and 64.7 per cent OG during; NA and 3.1 per cent NG, 13.3 per cent YG, and 34 per cent OG during EA. During NA and EA, cost was equal in YG and OG but greater than in NG. Outcomes after HRCP are worse for older patients and for nonelective cases. This information can inform preoperative counseling and targeted quality improvement projects. Further work is needed to understand geriatric-specific risk factors and outcomes to provide high-quality patient-centered care.

High-Risk Subgroup Membership Is a Predictor of 30-Day Morbidity Following Anterior Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine if membership in a high-risk subgroup is predictive of morbidity and mortality following anterior lumbar fusion (ALF).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify patients undergoing ALF between 2010 and 2014. Multivariate analysis was utilized to identify high-risk subgroup membership as an independent predictor of postoperative complications.

RESULTS

Members of the elderly (≥65 years) (OR = 1.3, P = .02) and non-Caucasian (black, Hispanic, other) (OR = 1.7, P < .0001) subgroups were at greater risk for a LOS ≥5 days. Obese patients (≥30 kg/m² ) were at greater risk for an operative time ≥4 hours (OR = 1.3, P = .005), and wound complications (OR = 1.8, P = .024) compared with nonobese patients. Emergent procedures had a significantly increased risk for LOS ≥5 days (OR = 4.9, P = .021), sepsis (OR = 14.8, P = .018), and reoperation (OR = 13.4, P < .0001) compared with nonemergent procedures. Disseminated cancer was an independent risk factor for operative time ≥4 hours (OR = 8.4, P < .0001), LOS ≥5 days (OR = 15.2, P < .0001), pulmonary complications (OR = 7.4, P = .019), and postoperative blood transfusion (OR = 3.1, P = .040).

CONCLUSIONS

High-risk subgroup membership is an independent risk factor for morbidity following ALF. These groups should be targets for aggressive preoperative optimization, and quality improvement initiatives.