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Cronin WA, Nealeigh MD, Zeien JL, Goc JM, Amoako MY, Velosky AG, Williman MC, Cyr KL, Highland KB. Opioid Prescribing Variation After Laparoscopic Cholecystectomy in the US Military Health System. J Surg Res 2024; 297:149-158. [PMID: 37604706 DOI: 10.1016/j.jss.2023.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION After laparoscopic cholecystectomy (LC), there is a wide variation in opioid prescription miligram morphine equivalent dose (MED) and refills across US medical institutions. Given wide variation and opioid prescription guidelines, it is essential to conduct thorough health services research across medical, surgical, and patient-level factors that can be implemented to improve system-wide prescribing practices. Therefore, this study describes discharge MED variation and opioid refill probability after emergent and nonemergent LC. MATERIALS AND METHODS This retrospective cohort study included medical record data of adult patients (N = 20,025) undergoing LC from January 2016 to June 2021 in the US Military Health System. Data visualizations and bivariate analyses examined prescription patterns across hospitals and evaluated the relationship between patient-level, care-level, and system-level factors and each outcome: discharge MED and opioid refill probability. Two generalized additive mixed models evaluated the relationship between predictors and each outcome. RESULTS There was a significant variation in opioid and nonopioid pain medication prescribing practices across hospitals. While several factors were associated with discharge MED and opioid refill probability, the strongest effects were related to time period (before versus after a June 2018 Defense Health Agency policy release) and receipt of an opioid/nonopioid combination medication. Despite decreases in MED, the MED remained almost twice the recommended dose per prior research. CONCLUSIONS Variation by hospital suggests the need for system-level changes that target genuine practice change and opioid stewardship. Inclusion of patient-reported outcomes, electronic health record decision support tools, and academic detailing programs may support system-level improvements.
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Affiliation(s)
- William A Cronin
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland; Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland
| | - Matthew D Nealeigh
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland; Department of Surgery, Uniformed Services University, Bethesda, Maryland
| | - Justin L Zeien
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Jonathan M Goc
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Maxwell Y Amoako
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Rockville, Maryland; Enterprise Intelligence and Data Solutions (EIDS) Program Office, Program Executive Office, Defense Healthcare Management Systems (PEO DHMS), San Antonio, Texas
| | - Alexander G Velosky
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Rockville, Maryland; Enterprise Intelligence and Data Solutions (EIDS) Program Office, Program Executive Office, Defense Healthcare Management Systems (PEO DHMS), San Antonio, Texas
| | - Melina C Williman
- School of Medicine, Uniformed Services University, Bethesda, Maryland; Department of Anesthesiology, Brooke Army Medical Center, San Antonio, Texas
| | - Kyle L Cyr
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland; Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland.
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Unalp-Arida A, Ruhl CE. Burden of gallstone disease in the United States population: Prepandemic rates and trends. World J Gastrointest Surg 2024; 16:1130-1148. [PMID: 38690054 PMCID: PMC11056655 DOI: 10.4240/wjgs.v16.i4.1130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/23/2024] [Accepted: 03/20/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Gallstone disease is one of the most common digestive disorders in the United States and leads to significant morbidity, mortality, and health care utilization. AIM To expand on earlier findings and investigate prepandemic rates and trends in the gallstone disease burden in the United States using national survey and claims databases. METHODS The National Ambulatory Medical Care Survey, National Inpatient Sample, Nationwide Emergency Department Sample, Nationwide Ambulatory Surgery Sample, Vital Statistics of the United States, Optum Clinformatics® Data Mart, and Centers for Medicare and Medicaid Services Medicare 5% Sample and Medicaid files were used to estimate claims-based prevalence, medical care including cholecystectomy, and mortality with a primary or other gallstone diagnosis. Rates were age-adjusted (for national databases) and shown per 100000 population. RESULTS Gallstone disease prevalence (claims-based, 2019) was 0.70% among commercial insurance enrollees, 1.03% among Medicaid beneficiaries, and 2.09% among Medicare beneficiaries and rose over the previous decade. Recently, in the United States population, gallstone disease contributed to approximately 2.2 million ambulatory care visits, 1.2 million emergency department visits, 625000 hospital discharges, and 2000 deaths annually. Women had higher medical care rates with a gallstone disease diagnosis, but mortality rates were higher among men. Hispanics had higher ambulatory care visit and hospital discharge rates compared with Whites, but not mortality rates. Blacks had lower ambulatory care visit and mortality rates, but similar hospital discharge rates compared with whites. During the study period, ambulatory care and emergency department visit rates with a gallstone disease diagnosis rose, while hospital discharge and mortality rates declined. Among commercial insurance enrollees, rates were higher compared with national data for ambulatory care visits and hospitalizations, but lower for emergency department visits. Cholecystectomies performed in the United States included 605000 ambulatory laparoscopic, 280000 inpatient laparoscopic, and 49000 inpatient open procedures annually. Among commercial insurance enrollees, rates were higher compared with national data for laparoscopic procedures. CONCLUSION The gallstone disease burden in the United States is substantial and increasing, particularly among women, Hispanics, and older adults with laparoscopic cholecystectomy as the mainstay treatment. Current practice patterns should be monitored for better health care access.
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Affiliation(s)
- Aynur Unalp-Arida
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892-5458, United States
| | - Constance E Ruhl
- Social & Scientific Systems, Inc., DLH Holdings Corp Company, Silver Spring, MD 20910, United States
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Myers S, Kenzik K, Allee L, Dechert T, Theodore S, Jaffe A, Sanchez SE. Social Determinants of Health Associated With the Need for Urgent Versus Elective Cholecystectomy at an Urban, Safety-Net Hospital. Surg Infect (Larchmt) 2024; 25:101-108. [PMID: 38301176 DOI: 10.1089/sur.2023.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
Background: Benign gallstone disease is the most frequent indication for cholecystectomy in the United States. Many patients present with complicated disease requiring urgent interventions, which increases morbidity and mortality. We investigated the association between individual and population-level social determinants of health (SDoH) with urgent versus elective cholecystectomy. Patients and Methods: All patients undergoing cholecystectomy (2014-2021) for benign gallstone disease were included. Demographic and clinical data were linked to population-level SDoH characteristics using census tracts. Data were analyzed using descriptive and inferential statistics. Results: A total of 3,197 patients met inclusion criteria; 1,913 (59.84%) underwent urgent cholecystectomy, 1,204 (37.66%) underwent emergent cholecystectomy, and 80 (2.5%) underwent interval cholecystectomy. On multinomial logistic regression, patients who were older (relative risk [RR], 1.010; p < 0.001), black (RR, 1.634; p = 0.008), and living in census tracts with a higher percent of poverty (RR, 0.017; p = 0.021) had a higher relative risk of presenting for urgent cholecystectomy. Patients who were female (RR, 0.462; p < 0.001), had a primary care provider (PCP; RR, 0.821; p = 0.018), and lived in census tracts with low supermarket access (RR, 0.764; p = 0.038) had a lower relative risk of presenting for urgent cholecystectomy. Only age (RR, 1.066; p < 0.001), female gender (RR, 0.227; p < 0.001), and having a PCP (RR, 1.984; p = 0.034) were associated with presentation for interval cholecystectomy. Conclusions: Patients who were older, black, and living in census tracts with high poverty levels had a higher relative risk of presenting for urgent cholecystectomy at our institution, whereas females and patients with PCPs were more likely to undergo elective cholecystectomy. Improved access to primary care and surgical clinics for all patients at safety-net hospitals may result in improved outcomes in the management of benign gallstone disease by increasing diagnosis and treatment in the elective setting.
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Affiliation(s)
- Sara Myers
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Kelly Kenzik
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Lisa Allee
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Tracey Dechert
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Sheina Theodore
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Abraham Jaffe
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Sabrina E Sanchez
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
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Bakillah E, Sharpe J, Tong JK, Goldshore M, Morris JB, Kelz RR. Non-English Primary Language: A Growing Population's Access to Cholecystectomy. Ann Surg 2023; 278:e1175-e1179. [PMID: 37226825 DOI: 10.1097/sla.0000000000005919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To examine access to cholecystectomy and postoperative outcomes among non-English primary-speaking patients. BACKGROUND The population of U.S. residents with limited English proficiency is growing. Language affects health literacy and is a well-recognized barrier to health care in the United States of America. Historically marginalized communities are at greater risk of requiring emergent gallbladder operations. However, little is known about how primary language affects surgical access and outcomes of common surgical procedures, such as cholecystectomy. METHODS We conducted a retrospective cohort study of adult patients after receipt of cholecystectomy in Michigan, Maryland, and New Jersey utilizing the Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery and Services Database (2016-2018). Patients were classified by primary spoken language: English or non-English. The primary outcome was admission type. Secondary outcomes included operative setting, operative approach, in-hospital mortality, postoperative complications, and length of stay. Multivariable logistics and Poisson regression were used to examine outcomes. RESULTS Among 122,013 patients who underwent cholecystectomy, 91.6% were primarily English speaking and 8.4% were non-English primary language speaking. Primary non-English speaking patients had a higher likelihood of emergent/urgent admissions (odds ratio: 1.22, 95% CI: 1.04-1.44, P = 0.015) and a lower likelihood of having an outpatient operation (odds ratio: 0.80, 95% CI: 0.70-0.91, P = 0.0008). There was no difference in the use of a minimally invasive approach or postoperative outcomes based on the primary language spoken. CONCLUSIONS Non-English primary language speakers were more likely to access cholecystectomy through the emergency department and less likely to receive outpatient cholecystectomy. Barriers to elective surgical presentation for this growing patient population need to be further studied.
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Affiliation(s)
- Emna Bakillah
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA
- Leonard Davis Institute of Health Economics, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - James Sharpe
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA
| | - Jason K Tong
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA
- Leonard Davis Institute of Health Economics, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Matthew Goldshore
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Jon B Morris
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA
- Leonard Davis Institute of Health Economics, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
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Martin WT, Ball J, Patterson AK, Snyder KB, Bonds M, Stewart K, Sarwar Z, Raines AR, Cross A. Not all cholecystitis is created equal: Disparities contributing to ED presentation and failure of the outpatient algorithm. Am J Surg 2023; 226:835-839. [PMID: 37481409 DOI: 10.1016/j.amjsurg.2023.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND The majority of final surgical pathology (FSP) from both emergency department (ED) and outpatient clinic (OC) patients is chronic cholecystitis. We aimed to differentiate these presentations and identify disparities associated with ED utilization and OC failure. METHODS Retrospective chart review of single institution ED and OC cholecystectomies for cholelithiasis. Clinical presentation, FSP, demographics, and zip code poverty (ZCP) levels were evaluated. Data analysis by summary statistics, bivariate comparisons, and logistic regression. RESULTS Of 299 OC and 308 ED patients, OC was more likely to be Caucasian (78% vs 46%, p < 0.0001) and insured (89% vs. 32%, p < 0.0001). 71.8% of OC with ZCP <10% had insurance versus only 32.5% in ZCP >20%. Uninsured ED OR was 13.1 (95% CI 8.7-22.9). CONCLUSION Uninsured ED patients are vulnerable to fail the outpatient algorithm, especially when misdiagnosed by US. Clinical diagnosis of cholecystitis in this population should warrant offering of urgent cholecystectomy.
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Affiliation(s)
| | - Jonathan Ball
- University of Oklahoma General Surgery Department, USA.
| | | | | | - Morgan Bonds
- University of Oklahoma General Surgery Department, USA.
| | | | - Zoona Sarwar
- University of Oklahoma General Surgery Department, USA.
| | | | - Alisa Cross
- University of Oklahoma General Surgery Department, USA.
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Dupont B, Dejardin O, Bouvier V, Piquet MA, Alves A. Systematic Review: Impact of Social Determinants of Health on the Management and Prognosis of Gallstone Disease. Health Equity 2022; 6:819-835. [PMID: 36338799 PMCID: PMC9629913 DOI: 10.1089/heq.2022.0063] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Due to its prevalence, gallstone disease is a major public health issue. It affects diverse patient populations across various socioeconomic levels. Socioeconomic and geographic deprivation may impact both morbidity and mortality associated with digestive diseases, such as biliary tract disease. Aim: The aim of this systematic review was to review the available data on the impact of socioeconomic determinants and geographic factors on gallstone disease and its complications. Methods: This systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE and Web of Science databases were searched by two investigators to retrieve studies about the impact of income, insurance status, hospital status, education level, living areas, and deprivation indices on gallstone disease. Thirty-seven studies were selected for this review. Results: Socially disadvantaged populations appear to be more frequently affected by complicated or severe forms of gallstone disease. The prognosis of biliary tract disease is poor in these populations regardless of patient status, and increased morbidity and mortality were observed for acute cholangitis or subsequent cholecystectomy. Limited or delayed access and low-quality therapeutic interventions could be among the potential causes for this poor prognosis. Conclusions: This systematic review suggests that socioeconomic determinants impact the management of gallstone disease. Enhanced knowledge of these parameters could contribute to improved public health policies to manage these diseases.
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Affiliation(s)
- Benoît Dupont
- Departement d'Hepato-Gastroenterologie et Nutrition, UNICAEN, CHU de Caen Normandie, Normandie Univ, Caen, France
- “Anticipe” U1086 INSERM-UCBN, “Cancers & Preventions,” Team Labelled “League Against Cancer,” UNICAEN, Normandie Univ, CAEN, France
| | - Olivier Dejardin
- “Anticipe” U1086 INSERM-UCBN, “Cancers & Preventions,” Team Labelled “League Against Cancer,” UNICAEN, Normandie Univ, CAEN, France
- Registre des Tumeurs Digestives du Calvados, “Anticipe” U1086 INSERM-UCBN, UNICAEN, Normandie Univ, Caen, France
| | - Véronique Bouvier
- “Anticipe” U1086 INSERM-UCBN, “Cancers & Preventions,” Team Labelled “League Against Cancer,” UNICAEN, Normandie Univ, CAEN, France
- Registre des Tumeurs Digestives du Calvados, “Anticipe” U1086 INSERM-UCBN, UNICAEN, Normandie Univ, Caen, France
| | - Marie-Astrid Piquet
- Departement d'Hepato-Gastroenterologie et Nutrition, UNICAEN, CHU de Caen Normandie, Normandie Univ, Caen, France
| | - Arnaud Alves
- “Anticipe” U1086 INSERM-UCBN, “Cancers & Preventions,” Team Labelled “League Against Cancer,” UNICAEN, Normandie Univ, CAEN, France
- Service de Chirurgie Digestive, UNICAEN, CHU de Caen Normandie, Normandie Univ, Caen, France
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Use of a New Prevention Model in Acute Care Surgery. ANNALS OF SURGERY OPEN 2022; 3. [PMID: 35990734 PMCID: PMC9390954 DOI: 10.1097/as9.0000000000000188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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