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Khan MMM, Munir MM, Woldesenbet S, Khalil M, Endo Y, Katayama E, Altaf A, Dillhoff M, Obeng-Gyasi S, Pawlik TM. Disparities in clinical trial enrollment among patients with gastrointestinal cancer relative to minority-serving and safety-netting hospitals. J Gastrointest Surg 2024; 28:896-902. [PMID: 38555017 DOI: 10.1016/j.gassur.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/06/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND For results to be generalizable to all patients with cancer, clinical trials need to include a diverse patient demographic that is representative of the general population. We sought to characterize the effect of receiving care at a minority-serving hospital (MSH) and/or safety-net hospital on clinical trial enrollment among patients with gastrointestinal (GI) malignancies. METHODS Adult patients with GI cancer who underwent oncologic surgery and were enrolled in institutional-/National Cancer Institute-funded clinical trials between 2012 and 2019 were identified in the National Cancer Database. Multivariable regression was used to assess the relationship between MSH and safety-net status relative to clinical trial enrollment. RESULTS Among 1,112,594 patients, 994,598 (89.4%) were treated at a non-MSH, whereas 117,996 (10.6%) were treated at an MSH. Only 1857 patients (0.2%) were enrolled in a clinical trial; most patients received care at a non-MSH (1794 [96.6%]). On multivariable analysis, the odds of enrollment in a clinical trial were markedly lower among patients treated at an MSH vs non-MSH (odds ratio [OR], 0.32; 95% CI, 0.22-0.46). In addition, even after controlling for receipt of care at MSH, Black patients remained at lower odds of enrollment in a clinical trial than White patients (OR, 0.57; 95% CI, 0.45-0.73; both P < .05). CONCLUSION Overall, clinical trial participation among patients with GI cancer was extremely low. Patients treated at an MSH and high safety-net burden hospitals and Black individuals were much less likely to be enrolled in a clinical trial. Efforts should be made to improve trial enrollment and address disparities in trial representation.
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Affiliation(s)
- Muhammad Muntazir Mehdi Khan
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Muhammad Musaab Munir
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Selamawit Woldesenbet
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Mujtaba Khalil
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Yutaka Endo
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Erryk Katayama
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Abdullah Altaf
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Mary Dillhoff
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States.
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Wong P, Victorino GP, Miraflor E, Alseidi A, Maker AV, Thornblade LW. Impact of safety-net hospital burden on achievement of textbook oncologic outcomes following resection in for stage I-IV colorectal cancer. J Surg Oncol 2024; 129:284-296. [PMID: 37815003 DOI: 10.1002/jso.27474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/10/2023] [Accepted: 09/23/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND AND OBJECTIVES Textbook oncologic outcome (TOO) is a benchmark for high-quality surgical cancer care but has not been studied at safety-net hospitals (SNH). The study sought to understand how SNH burden affects TOO achievement in colorectal cancer. METHODS The National Cancer Database was queried for colorectal cancer patients who underwent resection for stage I-III plus stage IV with liver-only metastases (2010-2019). TOO was defined as R0 resection, AJCC-compliant lymphadenectomy (>12 nodes), no prolonged LOS, no 30-day mortality/readmission, and receipt of stage-appropriate adjuvant chemotherapy. RESULTS Of 487,195 patients, 66.7% achieved TOO. Lower achievement was explained by adequate lymphadenectomy (87.3%), non-prolonged LOS (76.3%), and receipt of adjuvant chemotherapy in stage III (60.3%) and IV (54.1%). Treatment at high burden hospitals (HBH, >10% Medicaid/uninsured) was a predictor of non-TOO (Stage I/II: OR 0.83, III: OR 0.86, IV: OR 0.83; all p < 0.001). Achieving TOO was associated with decreased mortality (Stage I/II: HR 0.49, III: HR 0.48, IV: HR 0.57; all p < 0.001), and HBH treatment was a predictor of mortality (Stage I/II: HR 1.09, III: HR 1.05, IV: HR 1.07; all p < 0.05). CONCLUSIONS Treatment at higher SNH burden hospitals was associated with less frequent TOO achievement and increased mortality. Quality improvement targets include receipt of adjuvant chemotherapy and avoidance of prolonged LOS.
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Affiliation(s)
- Paul Wong
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Gregory P Victorino
- Department of Surgery, UCSF-East Bay Program, Highland Hospital, Oakland, California, USA
| | - Emily Miraflor
- Department of Surgery, UCSF-East Bay Program, Highland Hospital, Oakland, California, USA
| | - Adnan Alseidi
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Lucas W Thornblade
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
- Department of Surgery, UCSF-East Bay Program, Highland Hospital, Oakland, California, USA
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Wong P, Victorino GP, Sadjadi J, Knopf K, Maker AV, Thornblade LW. Surgical Cancer Care in Safety-Net Hospitals: a Systematic Review. J Gastrointest Surg 2023; 27:2920-2930. [PMID: 37968551 DOI: 10.1007/s11605-023-05867-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 10/08/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Tertiary medical centers in the USA provide specialized, high-volume surgical cancer care, contributing standards for quality and outcomes. For the most vulnerable populations, safety-net hospitals (SNHs) remain the predominant provider of both complex and routine healthcare needs. The objective of this study was to evaluate access to and quality of surgical oncology care within SNHs. METHODS A comprehensive and systematic review of the literature was conducted using PubMed, EMBASE, and Cochrane Library databases to identify all studies (January 2000-October 2021) reporting the delivery of surgical cancer care at SNHs in the USA (PROSPERO #CRD42021290092). These studies describe the process and/or outcomes of surgical care for gastrointestinal, hepatopancreatobiliary, or breast cancer patients seeking treatment at SNHs. RESULTS Of 3753 records, 37 studies met the inclusion criteria. Surgical care for breast cancer (43%) was the most represented, followed by colorectal (30%) and hepatopancreatobiliary (16%) cancers. Financial constraints, cultural and language barriers, and limitations to insurance coverage were cited as common reasons for disparities in care within SNHs. Advanced disease at presentation was common among cancer patients seeking care at SNHs (range, 24-61% of patients). Though reports comparing cancer survival between SNHs and non-SNHs were few, results were mixed, underscoring the variability in care seen across SNHs. CONCLUSIONS These findings highlight barriers in care facing many cancer patients. Continued efforts should address improving both access and quality of care for SNH patients. Future models include a transition away from a two-tiered system of resourced and under-resourced hospitals toward an integrated cancer system.
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Affiliation(s)
- Paul Wong
- Department of Surgery, University of California, San Francisco, 1411 E 31St Street, Oakland, CA, 94602, USA
| | - Gregory P Victorino
- Department of Surgery, University of California, San Francisco, 1411 E 31St Street, Oakland, CA, 94602, USA
- Highland Hospital, 1411 E 31st Street, Oakland, CA, USA
| | - Javid Sadjadi
- Department of Surgery, University of New Mexico, Albuquerque, NM, USA
| | - Kevin Knopf
- Highland Hospital, 1411 E 31st Street, Oakland, CA, USA
| | - Ajay V Maker
- Department of Surgery, University of California, San Francisco, 1411 E 31St Street, Oakland, CA, 94602, USA
| | - Lucas W Thornblade
- Department of Surgery, University of California, San Francisco, 1411 E 31St Street, Oakland, CA, 94602, USA.
- Highland Hospital, 1411 E 31st Street, Oakland, CA, USA.
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Jacobs MA, Tetley JC, Kim J, Schmidt S, Brimhall BB, Mika V, Wang CP, Manuel LS, Damien P, Shireman PK. Association of Cumulative Colorectal Surgery Hospital Costs, Readmissions, and Emergency Department/Observation Stays with Insurance Type. J Gastrointest Surg 2023; 27:965-979. [PMID: 36690878 PMCID: PMC10133377 DOI: 10.1007/s11605-022-05576-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/17/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND/PURPOSE Medicare's Hospital Readmission Reduction Program disproportionately penalizes safety-net hospitals (SNH) caring for vulnerable populations. This study assessed the association of insurance type with 30-day emergency department visits/observation stays (EDOS), readmissions, and cumulative costs in colorectal surgery patients. METHODS Retrospective inpatient cohort study using the National Surgical Quality Improvement Program (2013-2019) with cost data in a SNH. The odds of EDOS and readmissions and cumulative variable (index hospitalization and all 30-day EDOS and readmissions) costs were modeled adjusting for frailty, case status, presence of a stoma, and open versus laparoscopic surgery. RESULTS The cohort had 245 private, 195 Medicare, and 590 Medicaid/uninsured cases, with a mean age 55.0 years (SD = 13.3) and 52.9% of the cases were performed on male patients. Most cases were open surgeries (58.7%). Complication rates were 41.8%, EDOS 12.0%, and readmissions 20.1%. Medicaid/uninsured had increased odds of urgent/emergent surgeries (aOR = 2.15, CI = 1.56-2.98, p < 0.001) and complications (aOR = 1.43, CI = 1.02-2.03, p = 0.042) versus private patients. Medicaid/uninsured versus private patients had higher EDOS (16.6% versus 4.1%) and readmissions (22.9% versus 14.3%) rates and higher odds of EDOS (aOR = 4.81, CI = 2.57-10.06, p < 0.001), and readmissions (aOR = 1.62, CI = 1.07-2.50, p = 0.025), while Medicare patients had similar odds versus private. Cumulative variable cost %change was increased for Medicare and Medicaid/uninsured, but Medicaid/uninsured was similar to private after adjusting for urgent/emergent cases. CONCLUSIONS Increased urgent/emergent cases in Medicaid/uninsured populations drive increased complications odds and higher costs compared to private patients, suggesting lack of access to outpatient care. SNH care for higher cost populations, receive lower reimbursements, and are penalized by value-based programs. Increasing healthcare access for Medicaid/uninsured patients could reduce urgent/emergent surgeries, resulting in fewer complications, EDOS/readmissions, and costs.
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Affiliation(s)
- Michael A Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Jasmine C Tetley
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Bradley B Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
- University Health, San Antonio, TX, USA
| | | | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Laura S Manuel
- Business Intelligence and Data Analytics, University of Texas Health Physicians, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Paul Damien
- Department of Information, Risk, and Operations Management, School of Business, University of Texas, Red McCombs, Austin, TX, USA
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA.
- University Health, San Antonio, TX, USA.
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, TX, USA.
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Schmidt S, Kim J, Jacobs MA, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. Independent Associations of Neighborhood Deprivation and Patient-level Social Determinants of Health with Textbook Outcomes after Inpatient Surgery. ANNALS OF SURGERY OPEN 2023; 4:e237. [PMID: 37588414 PMCID: PMC10427124 DOI: 10.1097/as9.0000000000000237] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Objective Assess associations of Social Determinants of Health (SDoH) using Area Deprivation Index (ADI), race/ethnicity and insurance type with Textbook Outcomes (TO). Summary Background Data Individual- and contextual-level SDoH affect health outcomes, but only one SDoH level is usually included. Methods Three healthcare system cohort study using National Surgical Quality Improvement Program (2013-2019) linked with ADI risk-adjusted for frailty, case status and operative stress examining TO/TO components (unplanned reoperations, complications, mortality, Emergency Department/Observation Stays and readmissions). Results Cohort (34,251 cases) mean age 58.3 [SD=16.0], 54.8% females, 14.1% Hispanics, 11.6% Non-Hispanic Blacks, 21.6% with ADI>85, and 81.8% TO. Racial and ethnic minorities, non-Private insurance, and ADI>85 patients had increased odds of urgent/emergent surgeries (aORs range: 1.17-2.83, all P<.001). Non-Hispanic Black patients, ADI>85 and non-Private insurances had lower TO odds (aORs range: 0.55-0.93, all P<.04), but ADI>85 lost significance after including case status. Urgent/emergent versus elective had lower TO odds (aOR=0.51, P<.001). ADI>85 patients had higher complication and mortality odds. Estimated reduction in TO probability was 9.9% (CI=7.2%-12.6%) for urgent/emergent cases, 7.0% (CI=4.6%-9.3%) for Medicaid, and 1.6% (CI=0.2%-3.0%) for non-Hispanic Black patients. TO probability difference for lowest-risk (White-Private-ADI≤85-elective) to highest-risk (Black-Medicaid-ADI>85-urgent/emergent) was 29.8% for very frail patients. Conclusion Multi-level SDoH had independent effects on TO, predominately affecting outcomes through increased rates/odds of urgent/emergent surgeries driving complications and worse outcomes. Lowest-risk versus highest-risk scenarios demonstrated the magnitude of intersecting SDoH variables. Combination of insurance type and ADI should be used to identify high-risk patients to redesign care pathways to improve outcomes. Risk adjustment including contextual neighborhood deprivation and patient-level SDoH could reduce unintended consequences of value-based programs.
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Affiliation(s)
- Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Michael A. Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Karyn B. Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
- UT Health Physicians Business Intelligence and Data Analytics, University of Texas Health San Antonio, San Antonio, Texas
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jonathan C. Silverstein
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas
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Tseng CC, Gao J, Barinsky GL, Fang CH, Grube JG, Patel P, Hsueh WD, Eloy JA. Effect of Hospital Safety Net Burden on Survival for Patients With Sinonasal Squamous Cell Carcinoma. Otolaryngol Head Neck Surg 2023; 168:413-421. [PMID: 35608906 DOI: 10.1177/01945998221099819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/22/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine factors associated with hospital safety net burden and its impact on survival for patients with sinonasal squamous cell carcinoma (SNSCC). STUDY DESIGN Retrospective database study. SETTING National Cancer Database from 2004 to 2016. METHODS SNSCC cases were identified in the National Cancer Database. Hospital safety net burden was defined by percentage of uninsured/Medicaid patients treated, namely ≤25% for low-burden hospitals, 26% to 75% for medium-burden hospitals, and >75% for high-burden hospitals (HBHs). Univariate and multivariate analyses were used to investigate patient demographics, clinical characteristics, and overall survival. RESULTS An overall 6556 SNSCC cases were identified, with 1807 (27.6%) patients treated at low-burden hospitals, 3314 (50.5%) at medium-burden hospitals, and 1435 (21.9%) at HBHs. On multivariate analysis, Black race (odds ratio [OR], 1.39; 95% CI, 1.028-1.868), maxillary sinus primary site (OR, 1.31; 95% CI, 1.036-1.643), treatment at an academic/research program (OR, 20.63; 95% CI, 8.868-47.980), and treatment at a higher-volume facility (P < .001) resulted in increased odds of being treated at HBHs. Patients with grade III/IV tumor (OR, 0.70; 95% CI, 0.513-0.949), higher income (P < .05), or treatment modalities other than surgery alone (P < .05) had lower odds. Survival analysis showed that hospital safety net burden status was not significantly associated with overall survival (log-rank P = .727). CONCLUSION In patients with SNSCC, certain clinicopathologic factors, including Black race, lower income, treatment at an academic/research program, and treatment at facilities in the West region, were associated with treatment at HBHs. Hospital safety net burden status was not associated with differences in overall survival. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Christopher C Tseng
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jeff Gao
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Gregory L Barinsky
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Christina H Fang
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, The University Hospital of Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jordon G Grube
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Albany Medical Center, Albany, New York, USA
| | - Prayag Patel
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Wayne D Hsueh
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Otolaryngology and Facial Plastic Surgery, Saint Barnabas Medical Center-RWJBarnabas Health, Livingston, New Jersey, USA
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Simon RC, Kim J, Schmidt S, Brimhall BB, Salazar CI, Wang CP, Wang Z, Sarwar ZU, Manuel LS, Damien P, Shireman PK. Association of Insurance Type With Inpatient Surgery 30-Day Complications and Costs. J Surg Res 2023; 282:22-33. [PMID: 36244224 DOI: 10.1016/j.jss.2022.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/10/2022] [Accepted: 09/15/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Safety-net hospitals (SNHs) have higher postoperative complications and costs versus low-burden hospitals. Do low socioeconomic status/vulnerable patients receive care at lower-quality hospitals or are there factors beyond providers' control? We studied the association of private, Medicare, and vulnerable insurance type with complications/costs in a high-burden SNH. METHODS Retrospective inpatient cohort study using National Surgical Quality Improvement Program (NSQIP) data (2013-2019) with cost data risk-adjusted by frailty, preoperative serious acute conditions (PASC), case status, and expanded operative stress score (OSS) to evaluate 30-day unplanned reoperations, any complication, Clavien-Dindo IV (CDIV) complications, and hospitalization variable costs. RESULTS Cases (Private 1517; Medicare 1224; Vulnerable 3648) with patient mean age 52.3 y [standard deviation = 14.7] and 47.3% male. Adjusting for frailty and OSS, vulnerable patients had higher odds of PASC (aOR = 1.71, CI = 1.39-2.10, P < 0.001) versus private. Adjusting for frailty, PASC and OSS, Medicare (aOR = 1.27, CI = 1.06-1.53, P = 0.009), and vulnerable (aOR = 2.44, CI = 2.13-2.79, P < 0.001) patients were more likely to undergo urgent/emergent surgeries. Vulnerable patients had increased odds of reoperation and any complications versus private. Variable cost percentage change was similar between private and vulnerable after adjusting for case status. Urgent/emergent case status increased percentage change costs by 32.31%. We simulated "switching" numbers of private (3648) versus vulnerable (1517) cases resulting in an estimated variable cost of $49.275 million, a 25.2% decrease from the original $65.859 million. CONCLUSIONS Increased presentation acuity (PASC and urgent/emergent surgeries) in vulnerable patients drive increased odds of complications and costs versus private, suggesting factors beyond providers' control. The greatest impact on outcomes may be from decreasing the incidence of urgent/emergent surgeries by improving access to care.
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Affiliation(s)
- Richard C Simon
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Bradley B Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, Texas; University Health, San Antonio, Texas
| | | | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Zhu Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Zaheer U Sarwar
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas; University Health, San Antonio, Texas
| | - Laura S Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Paul Damien
- Department of Information, Risk, and Operations Management, Red McCombs School of Business, University of Texas, Austin, Texas
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas; University Health, San Antonio, Texas; Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas.
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8
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Tetley JC, Jacobs MA, Kim J, Schmidt S, Brimhall BB, Mika V, Wang CP, Manuel LS, Damien P, Shireman PK. Association of Insurance Type With Colorectal Surgery Outcomes and Costs at a Safety-Net Hospital: A Retrospective Observational Study. ANNALS OF SURGERY OPEN 2022; 3:e215. [PMID: 36590892 PMCID: PMC9780053 DOI: 10.1097/as9.0000000000000215] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/02/2022] [Indexed: 11/09/2022] Open
Abstract
Association of insurance type with colorectal surgical complications, textbook outcomes (TO), and cost in a safety-net hospital (SNH). Background SNHs have higher surgical complications and costs compared to low-burden hospitals. How does presentation acuity and insurance type influence colorectal surgical outcomes? Methods Retrospective cohort study using single-site National Surgical Quality Improvement Program (2013-2019) with cost data and risk-adjusted by frailty, preoperative serious acute conditions (PASC), case status and open versus laparoscopic to evaluate 30-day reoperations, any complication, Clavien-Dindo IV (CDIV) complications, TO, and hospitalization variable costs. Results Cases (Private 252; Medicare 207; Medicaid/Uninsured 619) with patient mean age 55.2 years (SD = 13.4) and 53.1% male. Adjusting for frailty, open abdomen, and urgent/emergent cases, Medicaid/Uninsured patients had higher odds of presenting with PASC (adjusted odds ratio [aOR] = 2.02, 95% confidence interval [CI] = 1.22-3.52, P = 0.009) versus Private. Medicaid/Uninsured (aOR = 1.80, 95% CI = 1.28-2.55, P < 0.001) patients were more likely to undergo urgent/emergent surgeries compared to Private. Medicare patients had increased odds of any and CDIV complications while Medicaid/Uninsured had increased odds of any complication, emergency department or observations stays, and readmissions versus Private. Medicare (aOR = 0.51, 95% CI = 0.33-0.88, P = 0.003) and Medicaid/Uninsured (aOR = 0.43, 95% CI = 0.30-0.60, P < 0.001) patients had lower odds of achieving TO versus Private. Variable cost %change increased in Medicaid/Uninsured patients to 13.94% (P = 0.005) versus Private but was similar after adjusting for case status. Urgent/emergent cases (43.23%, P < 0.001) and any complication (78.34%, P < 0.001) increased %change hospitalization costs. Conclusions Decreasing the incidence of urgent/emergent colorectal surgeries, possibly by improving access to care, could have a greater impact on improving clinical outcomes and decreasing costs, especially in Medicaid/Uninsured insurance type patients.
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Affiliation(s)
- Jasmine C. Tetley
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Michael A. Jacobs
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Jeongsoo Kim
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, TX
- University Health, San Antonio, TX
| | | | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX
| | - Paul Damien
- Department of Information, Risk, and Operations Management, Red McCombs School of Business, University of Texas, Austin, TX
| | - Paula K. Shireman
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
- University Health, San Antonio, TX
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, TX
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9
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Malheiro R, Peleteiro B, Correia S. Beyond the operating room: do hospital characteristics have an impact on surgical site infections after colorectal surgery? A systematic review. Antimicrob Resist Infect Control 2021; 10:139. [PMID: 34593035 PMCID: PMC8485500 DOI: 10.1186/s13756-021-01007-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/07/2021] [Indexed: 12/16/2022] Open
Abstract
Background Hospital characteristics have been recognized as potential risk factors for surgical site infection for over 20 years. However, most research has focused on patient and procedural risk factors. Understanding how structural and process variables influence infection is vital to identify targets for effective interventions and to optimize healthcare services. The aim of this study was to systematically review the association between hospital characteristics and surgical site infection in colorectal surgery. Main body A systematic literature search was conducted using PubMed, Scopus and Web of Science databases until the 31st of May, 2021. The search strategy followed the Participants, Exposure/Intervention, Comparison, Outcomes and Study design. The primary outcome of interest was surgical site infection rate after colorectal surgery. Studies were grouped into nine risk factor typologies: hospital size, ownership affiliation, being an oncological hospital, safety-net burden, hospital volume, surgeon caseload, discharge destination and time since implementation of surveillance. The STROBE statement was used for evaluating the methodological quality. A total of 4703 records were identified, of which 172 were reviewed and 16 were included. Studies were published between 2008 and 2021, and referred to data collected between 1996 and 2016. Surgical site infection incidence ranged from 3.2 to 27.6%. Two out of five studies evaluating hospital size adjusted the analysis to patient and procedure-related risk factors, and showed that larger hospitals were either positively associated or had no association with SSI. Public hospitals did not present significantly different infection rates than private or non-profit ones. Medical school affiliation and higher safety-net burden were associated with higher surgical site infection (crude estimates), while oncological hospitals were associated with higher incidence independently of other variables. Hospital caseload showed mixed results, while surgeon caseload and surveillance time since implementation appear to be associated with fewer infections. Conclusions Although there are few studies addressing hospital-level factors on surgical site infection, surgeon experience and the implementation of a surveillance system appear to be associated with better outcomes. For hospitals and services to be efficiently optimized, more studies addressing these variables are needed that take into account the confounding effect of patient case mix.
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Affiliation(s)
- Rui Malheiro
- EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas 135, 4050-091, Porto, Portugal. .,Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal.
| | - Bárbara Peleteiro
- EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas 135, 4050-091, Porto, Portugal.,Department of Public Health and Forensic Sciences and Medical Education, Faculdade de Medicina, Universidade do Porto (University of Porto Medical School), Porto, Portugal.,Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal
| | - Sofia Correia
- EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas 135, 4050-091, Porto, Portugal.,Department of Public Health and Forensic Sciences and Medical Education, Faculdade de Medicina, Universidade do Porto (University of Porto Medical School), Porto, Portugal.,Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal
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10
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Stundner O, Zubizarreta N, Mazumdar M, Memtsoudis SG, Wilson LA, Ladenhauf HN, Poeran J. Differential Perioperative Outcomes in Patients With Obstructive Sleep Apnea, Obesity, or a Combination of Both Undergoing Open Colectomy: A Population-Based Observational Study. Anesth Analg 2021; 133:755-764. [PMID: 34153009 DOI: 10.1213/ane.0000000000005638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND An increasing body of evidence demonstrates an association between obstructive sleep apnea (OSA) and adverse perioperative outcomes. However, large-scale data on open colectomies are lacking. Moreover, the interaction of obesity with OSA is unknown. This study examines the impact of OSA, obesity, or a combination of both, on perioperative complications in patients undergoing open colectomy. We hypothesized that while both obesity and OSA individually increase the likelihood for perioperative complications, the overlap of the 2 conditions is associated with the highest risk. METHODS Patients undergoing open colectomies were identified using the national Premier Healthcare claims-based Database (2006-2016; n = 340,047). Multilevel multivariable models and relative excess risk due to interaction (RERI) analysis quantified the impact of OSA, obesity, or both on length and cost of hospitalization, respiratory and cardiac complications, intensive care unit (ICU) admission, mechanical ventilation, and inhospital mortality. RESULTS Nine thousand twenty-eight (2.7%) patients had both OSA and obesity diagnoses; 10,137 (3.0%) had OSA without obesity; and 33,692 (9.9%) had obesity without OSA. Although there were overlapping confidence intervals in the binary outcomes, the risk increase was found highest for OSA with obesity, intermediate for obesity without OSA, and lowest for OSA without obesity. The strongest effects were seen for respiratory complications: odds ratio (OR), 2.41 (2.28-2.56), OR, 1.40 (1.31-1.49), and OR, 1.50 (1.45-1.56), for OSA with obesity, OSA without obesity, and obesity without OSA, respectively (all P < .0001). RERI analysis revealed a supraadditive effect of 0.51 (95% confidence interval [CI], 0.34-0.68) for respiratory complications, 0.11 (-0.04 to 0.26) for cardiac complications, 0.30 (0.14-0.45) for ICU utilization, 0.34 (0.21-0.47) for mechanical ventilation utilization, and 0.26 (0.15-0.37) for mortality in patients with both OSA and obesity, compared to the sum of the conditions' individual risks. Inhospital mortality was significantly higher in patients with both OSA and obesity (OR [CI], 1.21 [1.07-1.38]) but not in the other groups. CONCLUSIONS Both OSA and obesity are individually associated with adverse perioperative outcomes, with a supraadditive effect if both OSA and obesity are present. Interventions, screening, and perioperative precautionary measures should be tailored to the respective risk profile. Moreover, both conditions appear to be underreported compared to the general population, highlighting the need for stringent perioperative screening, documentation, and reporting.
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Affiliation(s)
- Ottokar Stundner
- From the Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.,Department of Anesthesiology and Critical Care, Medical University of Innsbruck, Innsbruck, Austria
| | - Nicole Zubizarreta
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Madhu Mazumdar
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stavros G Memtsoudis
- From the Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.,Department of Anesthesiology & Public Health, Weill Cornell Medical College, New York, New York.,Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Lauren A Wilson
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Hannah N Ladenhauf
- Department of Pediatric and Adolescent Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Jashvant Poeran
- Departments of Orthopaedic Surgery, Population Health Science & Policy, and Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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