Insurance status predicts access to care and outcomes of vascular disease

Factors Associated with Urgent Amputation Status and Its Impact on Mortality

BACKGROUND

Thirty-day mortality is higher after urgent major lower extremity amputations compared to elective lower extremity amputations. This study aims to identify factors associated with urgent amputations and to examine their impact on perioperative outcomes and long-term mortality.

METHODS

Patients undergoing major lower limb amputation from 2013 to 2020 in the Vascular Quality Initiative were included. Urgent amputation was defined as occurring within 72 hr of admission. Associations with sociodemographic characteristics, comorbidities, and outcomes including postoperative complication, inpatient death, and long-term survival were compared using univariable tests and multivariable logistic regression. Long-term survival between groups was compared using Kaplan-Meier analysis.

RESULTS

Of the 12,874 patients included, 4,850 (37.7%) had urgent and 8,024 (62.3%) had elective amputations. Non-White patients required urgent amputation more often than White patients (39.8% vs. 37.9%, P = 0.03). A higher proportion of Medicaid and self-pay patients presented urgently (Medicaid: 13.0% vs. 11.0%; self-pay: 3.4% vs. 2.5%, P < 0.001). Patients requiring urgent amputation were less often taking aspirin (55.6% vs. 60.1%, P < 0.001) or statin (62.2% vs. 67.2%, P < 0.001), had fewer prior revascularization procedures (41.0% vs. 48.8%, P < 0.001), and were of higher American Society of Anesthesiologists (ASA) class 4-5 (50.9% vs. 40.1%, P < 0.001). Urgent amputations were more commonly for uncontrolled infection (48.1% vs. 29.4%, P < 0.001) or acute limb ischemia (14.3% vs. 6.2%, P < 0.001). Postoperative complications were higher after urgent amputations (34.7% vs. 16.6%, P < 0.001), including need for return to operating room (23.8% vs. 8.4%, P < 0.001) and need for higher revision (15.2% vs. 4.5%, P < 0.001). Inpatient mortality was higher after urgent amputation (8.9% vs. 5.4%, P < 0.001). Multivariable analysis revealed non-White race, self-pay, homelessness, current smoking, ASA class 4-5, and amputations for uncontrolled infection or acute limb ischemia were associated with urgent status, whereas living in a nursing home or prior revascularization were protective. Furthermore, urgent amputation was associated with an increased odds of postoperative complication or death (odds ratio 1.86 [1.69-2.04], P < 0.001) as well as long-term mortality (odds ratio: 1.24 [1.13-1.35], P < 0.001). Kaplan-Meier analysis corroborated that elective status was associated with improvement of long-term survival.

CONCLUSIONS

Patients requiring urgent amputations are more often non-White, uninsured, and less frequently had prior revascularization procedures, revealing disparities in access to care. Urgency was associated with a higher postoperative complication rate, as well as increased long-term mortality. Efforts should be directed toward reducing these disparities to improve outcomes following amputation.

Impact of Insurance Type on Access to Pediatric Surgical Care

Background

This study aimed to measure the impact of insurance type on access to pediatric surgical care, clinical and surgical scheduling decisions, provider-driven cancelations, and missed care opportunities (MCOs). We hypothesize that patients with public health insurance experience longer scheduling delays and more frequently canceled surgical appointments compared with patients with private health insurance.

Methods

This retrospective study reviewed the demographics and clinical characteristics of patients who underwent a surgical procedure within the plastic and oral surgery department at our institution in 2019. Propensity score matching and linear regressions were used to estimate the effect of insurance type on hospital scheduling and patient access outcomes while controlling for procedure type and sex.

Results

A total of 457 patients were included in the demographic and clinical characteristics analyses; 354 were included in propensity score matching analyses. No significant differences in the number of days between scheduling and occurrence of initial consultation or number of clinic cancelations were observed between insurance groups (P > 0.05). However, patients with public insurance had a 7.4 times higher hospital MCO rate (95% CI [5.2-9.7]; P < 0.001) and 4.7 times the number of clinic MCOs (P = 0.007).

Conclusions

No significant differences were found between insurance groups in timely access to surgical treatment or cancelations. Patients with public insurance had more MCOs than patients with private insurance. Future research should investigate how to remove barriers that impact access to care for marginalized patients.

The impact of the Affordable Care Act Medicaid Expansion in Medicare beneficiaries with peripheral artery disease

Background: In 2014, the Affordable Care Act Medicaid Expansion (ME) increased Medicaid eligibility for adults with an income level up to 138% of the federal poverty level. In this study, we examined the impact of ME on mortality and amputation in patients with peripheral artery disease (PAD). Methods: The 100% MedPAR and Part-B Carrier files from 2011 to 2018 were queried to identify all fee-for-service Medicare beneficiaries with PAD using International Classification of Diseases codes. Our primary exposure was whether a state had adopted the ME on January 1, 2014. Our primary outcomes were the change in all-cause 1-year mortality and leg amputation. We used a state-level difference-in-differences (DID) analysis to compare the rates of the primary outcomes among patients who were in states (including the District of Columbia) who adopted ME (n = 25) versus those who were in states that did not (n = 26). We performed a subanalysis stratifying by sex, race, region, and dual-eligibility status. Results: Over the 8-year period, we studied 37,743,929 patients. The average unadjusted 1-year mortality decreased from 2011 to 2018 in both non-ME (9.5% to 8.7%, p < 0.001) and ME (9.1% to 8.3%, p < 0.001) states. The average unadjusted 1-year amputation rate did not improve in either the non-ME (0.86% to 0.87%, p = 0.17) or ME (0.69% to 0.69%, p = 0.65) states. Across the entire cohort, the DID model revealed that ME did not lead to a significant change in mortality (p = 0.15) or amputation (p = 0.34). Conclusion: Medicaid Expansion was not associated with reduced mortality or leg amputation in Medicare beneficiaries with PAD.

Including socioeconomic status reduces readmission penalties to safety-net hospitals

OBJECTIVE

Medicare's Hospital Readmissions Reduction Program (HRRP) financially penalizes "excessive" postoperative readmissions. Concerned with creating a double standard for institutions treating a high percentage of economically vulnerable patients, Medicare elected to exclude socioeconomic status (SES) from its risk-adjustment model. However, recent evidence suggests that safety-net hospitals (SNHs) caring for many low-SES patients are disproportionately penalized under the HRRP. We sought to simulate the impact of including SES-sensitive models on HRRP penalties for hospitals performing lower extremity revascularization (LER).

METHODS

This is a retrospective, cross-sectional analysis of national data on Medicare patients undergoing open or endovascular LER procedures between 2007 and 2009. We used hierarchical logistic regression to generate hospital risk-standardized 30-day readmission rates under Medicare's current model (adjusting for age, sex, comorbidities, and procedure type) compared with models that also adjust for SES. We estimated the likelihood of a penalty and penalty size for SNHs compared with non-SNHs under the current Medicare model and these SES-sensitive models.

RESULTS

Our study population comprised 1708 hospitals performing 284,724 LER operations with an overall unadjusted readmission rate of 14.4% (standard deviation: 5.3%). Compared with the Centers for Medicare and Medicaid Services model, adjusting for SES would not change the proportion of SNHs penalized for excess readmissions (55.1% vs 53.4%, P = .101) but would reduce penalty amounts for 38% of SNHs compared with only 17% of non-SNHs, P < .001.

CONCLUSIONS

For LER, changing national Medicare policy to including SES in readmission risk-adjustment models would reduce penalty amounts to SNHs, especially for those that are also teaching institutions. Making further strides toward reducing the national disparity between SNHs and non-SHNs on readmissions, performance measures require strategies beyond simply altering the risk-adjustment model to include SES.

Association between hospital racial composition and aortic valve replacement outcomes: A national inpatients sample database analysis

BACKGROUND

Racial and ethnic disparities exist in the outcomes following surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI). However, it is unclear whether hospital racial composition contributes to these racial disparities.

METHODS

We analyzed the National Inpatient Sample (NIS) database from 2015 to 2019 to identify patients with aortic stenosis (AS) who received SAVR and TAVI. The Racial/Ethnic Diversity Index (RDI) was used to assess hospital racial composition as the proportion of nonwhite patients to total hospital admissions. Hospitals were categorized into RDI quintiles. Textbook outcome (TO) was defined as no in-hospital mortality, no postoperative complications and no prolonged length of stay (LOS). Multivariable mixed generalized linear models were conducted to assess the association between RDI and post-SAVR and post-TAVI outcomes. Moreover, quantile regression was used to assess the additional cost and length of stay associated with the RDI quintile.

RESULTS

The study included 82,502 SAVR or TAVI performed across 3285 hospitals, with 47.4% isolated SAVR and 52.5% isolated TAVI. After adjustment, quintiles 4 and 5 demonstrated significantly lower odds of TO than the lowest RDI quintile in both the SAVR cohort (quintile 4, 0.79 [95% CI, 0.73-0.85]; quintile 5, 0.79 [95% CI, 0.73-0.86]) and TAVI cohort (quintile 4, 0.88 [95% CI, 0.82-0.95]; quintile 5, 0.80 [95% CI, 0.74-0.86]). Despite non-observable differences in in-hospital mortality across all RDI quintiles, the rate of AKI and blood transfusion increased with increasing RDI for both cohorts. Further, Higher RDI quintiles were associated with increased costs and longer LOS. From 2015 to 2019, post-TAVI outcomes improved across all RDI quintiles.

CONCLUSIONS

Hospitals with a higher RDI experienced lower TO achievements, increased AKI, and blood transfusion, along with extended LOS and higher costs. Importantly, post-TAVI outcomes improved from 2015 to 2019 across all RDI groups.

A systematic review and meta-analysis on the influence of sociodemographic factors on amputation in patients with peripheral arterial disease

OBJECTIVE

To identify disparities in sociodemographic factors that are associated with major lower limb amputation in patients with peripheral arterial disease (PAD).

METHODS

A systematic review of the literature was performed to identify studies that reported major lower limb amputation rates in patients with PAD among different sociodemographic groups. Data that compared amputation rates on the basis of sex, race, ethnicity, income, insurance, geography, and hospital type were collected and described. Outcomes were then aggregated and standardized, and a meta-analysis was performed to synthesis data into single odds ratios (ORs).

RESULTS

Forty-one studies were included in the review. There was no association found between males and females (OR, 0.95; 95% confidence interval [CI], 0.90-1.00). Compared with Whites, higher rates of amputation were seen among Blacks/African Americans (OR, 2.02; 95% CI, 1.81-2.26) and Native Americans (OR, 1.22; 95% CI, 1.04-1.45). No significant association was found between Whites and Asians, Native Hawaiians, or Pacific Islanders (OR, 1.15; 95% CI, 1.00-1.33). Hispanics had higher rates of amputation compared with non-Hispanics (OR, 1.36; 95% CI, 1.22-1.52). Compared with private insurance, higher rates of amputation were seen among Medicare patients (OR, 1.38; 95% CI, 1.27-1.50), Medicaid patients (OR, 1.59; 95% CI, 1.44-1.76), and noninsured patients (OR, 1.41; 95% CI, 1.02-1.95). Compared with the richest income quartile, higher rates of amputation were seen among the second income quartile (OR, 1.10; 95% CI, 1.05-1.15), third income quartile (OR, 1.20; 95% CI, 1.07-1.35), and bottom income quartile (OR, 1.36; 95% CI, 1.24-1.49). There was no association found between rural and urban populations (OR, 1.35; 95% CI, 0.92-1.97) or between teaching and nonteaching hospitals (OR, 1.01; 95% CI, 0.91-1.12).

CONCLUSIONS

Our study has identified a number of disparities and quantified the influence of sociodemographic factors on major lower limb amputation rates owing to PAD between groups. We believe these findings can be used to better target interventions aimed at decreasing amputation rates, although further research is needed to better understand the mechanisms behind our findings.

Self-pay insurance status is associated with failure of medical therapy in patients with acute uncomplicated type B aortic dissection

BACKGROUND

Traditionally, acute uncomplicated type B aortic dissections are managed medically, and acute complicated dissections are managed surgically. Self-pay patients with medically managed acute uncomplicated type B aortic dissections may fare worse than their insured counterparts.

METHODS

In this single-center, retrospective cohort study, demographics, follow-up, and outcomes of patients with acute type B aortic dissections from 2011 to 2020 were analyzed.

RESULTS

In total, 159 patients presented with acute type B aortic dissections; 102 were complicated and managed with thoracic endovascular aortic repair, and 57 were uncomplicated and managed medically. A total of 32% (n = 51) were self-pay. Self-pay patients were from areas with worse area deprivation indices (71% vs 63%, P = .024). They more often reported alcohol abuse (28% vs 7%, P < .001), cocaine/methamphetamine use (16% vs 5%, P = .028), and nonadherence to home antihypertensives (35% vs 11%, P < .001). Self-pay patients less often had a primary care physician (65% vs 7%, P < .001) or took antihypertensives before admission (31% vs 58%, P = .003). Self-pay patients frequently required financial assistance at discharge (63%), most often using charity funds (46%). Few patients (7%) qualified for our hospital's financial assistance program, and most (78%) remained uninsured at the first follow-up. Self-pay acute uncomplicated type B aortic dissections patients had the lowest rate of follow-up (31% vs 66%, P < .001) and were more likely to represent emergently (75% vs 0%, P = .033) compared to insured acute uncomplicated type B aortic dissections patients. Self-pay patients were more likely to follow up after thoracic endovascular aortic repair for acute complicated type B aortic dissections (82% vs 31%, P < .001).

CONCLUSION

Self-pay patients have multiple, interconnected, complex socioeconomic factors that likely influence preadmission risk for dissection and post-discharge adherence to optimal medical management. Further research is needed to clarify treatment strategies in this high-risk group.

Direct and Indirect Effects of Race and Socioeconomic Deprivation on Outcomes After Lower Extremity Bypass

OBJECTIVE

To evaluate the potential pathway, through which race and socioeconomic status, as measured by the social deprivation index (SDI), affect outcomes after lower extremity bypass chronic limb-threatening ischemia (CLTI), a marker for delayed presentation.

BACKGROUND

Racial and socioeconomic disparities persist in outcomes after lower extremity bypass; however, limited studies have evaluated the role of disease severity as a mediator to potentially explain these outcomes using clinical registry data.

METHODS

We captured patients who underwent lower extremity bypass using a statewide quality registry from 2015 to 2021. We used mediation analysis to assess the direct effects of race and high values of SDI (fifth quintile) on our outcome measures: 30-day major adverse cardiac event defined by new myocardial infarction, transient ischemic attack/stroke, or death, and 30-day and 1-year surgical site infection (SSI), amputation and bypass graft occlusion.

RESULTS

A total of 7077 patients underwent a lower extremity bypass procedure. Black patients had a higher prevalence of CLTI (80.63% vs 66.37%, P < 0.001). In mediation analysis, there were significant indirect effects where Black patients were more likely to present with CLTI, and thus had increased odds of 30-day amputation [odds ratio (OR): 1.11, 95% CI: 1.068-1.153], 1-year amputation (OR: 1.083, 95% CI: 1.045-1.123) and SSI (OR: 1.052, 95% CI: 1.016-1.089). There were significant indirect effects where patients in the fifth quintile for SDI were more likely to present with CLTI and thus had increased odds of 30-day amputation (OR: 1.065, 95% CI: 1.034-1.098) and SSI (OR: 1.026, 95% CI: 1.006-1.046), and 1-year amputation (OR: 1.068, 95% CI: 1.036-1.101) and SSI (OR: 1.026, 95% CI: 1.006-1.046).

CONCLUSIONS

Black patients and socioeconomically disadvantaged patients tended to present with a more advanced disease, CLTI, which in mediation analysis was associated with increased odds of amputation and other complications after lower extremity bypass compared with White patients and those that were not socioeconomically disadvantaged.

Correlating state-specific and national trends in breast reconstruction after Medicaid expansion: A decade-long update on the Affordable Care Act's impact

While disparities in access to reconstruction persist, a comprehensive analysis comparing state-based outcomes and national patterns in breast reconstruction as a result of Medicaid expansion has never been examined. In this study, we investigated how breast reconstruction rates changed as a result of Medicaid expansion and compared these state-based findings to national counterparts. Patient data from the Healthcare Cost and Utilization Project among states that chose to expand Medicaid were compared with those from states that did not expand. The difference-in-differences estimate of expansion to nonexpansion states was 7.05 (p = 0.10) for implant-based reconstruction, -11.56 (p = 0.01) for autologous reconstruction, and -7.08 (p = 0.18) for overall reconstruction. Comparing rates of nonexpansion states to national trends yielded estimates of -0.06 (p = 0.04), 0.06 (p = 0.01), and 0.004 (p = 0.90) for implant-based, autologous, and overall breast reconstruction, respectively. Similarly, comparing rates of expansion states to national trends yielded estimates of 0.02 (p = 0.38), -0.05 (p = 0.03), and -0.02 (p = 0.44) for implant-based, autologous, and overall breast reconstruction, respectively. In this study on national health policy, Medicaid expansion was associated with a significant increase in autologous rates while state-specific trends alone did not appear to predict the national outcomes of sweeping legislative changes that were differentially applied among states.

Disparities in healthcare utilization by insurance status among patients with symptomatic peripheral artery disease

BACKGROUND

Peripheral artery disease (PAD) is a common circulatory disorder associated with increased hospitalizations and significant health care-related expenditures. Among patients with PAD, insurance status is an important determinant of health care utilization, treatment of disease, and treatment outcomes. However, little is known about PAD-costs differences across different insurance providers. In this study we examined possible disparities in length of stay and total charge of inpatient hospitalizations among patients with PAD by insurance type.

METHODS

We conducted a cross-sectional analysis of length of stay and total charge by insurance provider for all hospitalizations for individuals with PAD in South Carolina (2010-2018). Cross-classified multilevel modeling was applied to account for the non-nested hierarchical structure of the data, with county and hospital included as random effects. Analyses were adjusted for patient age, race/ethnicity, county, year of admission, admission type, all-patient refined diagnostic groups, and Charlson comorbidity index.

RESULTS

Among 385,018 hospitalizations for individuals with PAD in South Carolina, the median length of stay was 4 days (IQR: 5) and the median total charge of hospitalization was $43,232 (IQR: $52,405). Length of stay and total charge varied significantly by insurance provider. Medicare patients had increased length of stay (IRR = 1.08, 95 CI%: 1.07, 1.09) and higher total charges (β: 0.012, 95% CI: 0.007, 0.178) than patients with private insurance. Medicaid patients also had increased length of stay (IRR = 1.26, 95% CI: 1.24,1.28) but had lower total charges (β: -0.022, 95% CI: -0.003. -0.015) than patients with private insurance.

CONCLUSIONS

Insurance status was associated with inpatient length of stay and total charges in patients with PAD. It is essential that Medicare and Medicaid individuals with PAD receive proper management and care of their PAD, particularly in the primary care settings, to prevent hospitalizations and reduce the excess burden on these patients.

The Association of Insurance Status and Complications After Carpal Tunnel Release

BACKGROUND

Carpal tunnel release (CTR) is one of the most commonly performed procedures in hand surgery. Complications from surgery are a rare but significant patient dissatisfier. The purpose of this study was to determine whether insurance status is independently associated with complications after CTR.

METHODS

We retrospectively identified all patients undergoing CTR between 2008 and 2018 using the Indiana Network for Patient Care, a state-wide health information exchange, and built a database that included patient demographics and comorbidities. Patients were followed for 90 days to determine whether a postoperative complication occurred. To minimize dropout, only patients with 1 year of encounters after surgery were included.

RESULTS

Of the 26 151 patients who met inclusion criteria, 2662 (10.2%) had Medicare, 7027 (26.9%) had Medicaid, and 16 462 (62.9%) had commercial insurance. Compared with Medicare, Medicaid status (P < .001) and commercial insurance status (P < .001) were independently associated with postoperative CTR complications. The overall complication rate was 2.23%, with infection, wound breakdown, and complex regional pain syndrome being the most common complications. Younger age, alcohol use, diabetes mellitus, hypertension, and depression were also independently associated with complications.

CONCLUSIONS

The incidence of complications after CTR is low. Insurance status, patient demographics, and medical comorbidities, however, should be evaluated preoperatively to appropriately risk stratify patients. Furthermore, surgeons can use these data to initiate preventive measures such as working to manage current comorbidities and lifestyle choices, and to optimize insurance coverage.

Increased Medicaid eligibility of Affordable Care Act: Evidence of improved outcomes for patients with peripheral artery disease

Peripheral artery disease (PAD) is a debilitating disease that disproportionately affects people of low socioeconomic status and racial minority individuals. These groups also tend to have lower rates of revascularization and worse outcomes, including higher rates of major amputation. In 2010, the Affordable Care Act (ACA) was signed into law, providing better opportunities for health care access to millions of uninsured Americans, although the implementation of different components started at a later date. Political issues led to uneven adaptation by states of the different ACA components. In states that adopted Medicaid expansion under the ACA, similar to that under the Massachusetts Health Care Reform Law of 2006, patients of low socioeconomic status and racial minority patients gained better access to health care. This review article will examine the disparities that exist in peripheral artery disease outcomes, as well as the effects of the ACA and Medicaid expansion on revascularization, limb salvage, and major amputation rates.

Effect of socioeconomic status on patients undergoing elective abdominal aortic aneurysm repair in a publicly funded health care system

BACKGROUND

The association between socioeconomic status (SES) and outcomes after abdominal aortic aneurysm (AAA) repair in publicly funded health care systems is poorly described. The purpose of this study was to determine the effect of SES on postoperative outcomes in patients who underwent AAA repair in Nova Scotia, Canada.

METHODS

We performed a retrospective analysis of all elective AAA repairs in Nova Scotia between November 2005 and March 2015 using administrative data sources. We compared postoperative 30-day outcomes and long-term survival across socio-economic quintiles, defined as the Pampalon Material Deprivation Index (MDI) and Social Deprivation Index (SDI). We also compared the relation between baseline characteristics, MDI quintile, SDI quintile and 30-day mortality. We used multivariable logistic regression and survival analysis to calculate adjusted 30-day mortality and long-term survival, respectively.

RESULTS

A total of 1913 patients underwent AAA repair during the study period. The overall 30-day mortality rate was 2.6% (50 patients). Thirty-day outcomes including death (p = 0.8), stroke (p = 0.7), myocardial infarction (p = 0.06), length of stay (p = 0.3) and discharge disposition other than home (p = 0.8) were similar across MDI quintiles. Similarly, there was no statistically significant association between SDI quintile and postoperative outcomes. Multivariable analysis showed that age greater than 70 years (odds ratio [OR] 3.06, 95% confidence interval [CI] 1.55-6.06) and open repair (OR 3.22, 95% CI 1.59-6.52) but not MDI quintile (p = NS) or SDI quintile (p = NS) were associated with increased 30-day mortality. There was no effect of MDI or SDI quintile on long-term survival on univariable or multivariable analysis.

CONCLUSION

Socioeconomic status does not appear to affect short- or long-term mortality after AAA repair in a publicly funded health care system. Further research is needed to address any existing gaps in screening and referral before repair.

Racial disparities in treatment of ruptured abdominal aortic aneurysms

OBJECTIVE

The Society for Vascular Surgery has recommended immediate transfer of patients with ruptured abdominal aortic aneurysms (rAAAs) to a regional center when feasible. However, Black patients might be less likely to be transferred and more likely to be turned down for repair. We, therefore, examined the transfer rates, turndown rates, and outcomes for Black vs White patients presenting with rAAAs in two large databases.

METHODS

We examined all rAAA repairs in the Vascular Quality Initiative from 2003 to 2020 to evaluate the transfer rates and outcomes for Black vs White patients. We used the National Inpatient Sample from 2004 to 2015 to examine the turndown rates. Mixed effects logistic regression, Cox regression, and marginal effects modeling were used to study the interaction between race, insurance status, surgery type (open repair vs endovascular aortic aneurysm repair), and hospital volume.

RESULTS

We identified 4935 patients with rAAAs in the Vascular Quality Initiative (6.2% Black) and 48,489 in the National Inpatient Sample (6.0% Black). The rates of transfer were high; however, Black patients were significantly less likely to undergo transfer before repair compared with White patients (49% Black vs 62% White; P = .002). The result was consistent in both crude and adjusted analyses when considering only stable patients and was not modified by insurance status, surgery type, or hospital volume. No significant differences were found in perioperative mortality (22% vs 26%; P = .098) or complications (52% vs 52%; P = .64). However, Black patients were significantly more likely to be turned down for repair (37% vs 28%; odds ratio, 1.5; 95% confidence interval, 1.2-1.9; P < .001). A significant interaction was found between race and insurance status with respect to turndown. Patients with private insurance had undergone surgery at a similar rate, regardless of race. However, among patients with Medicare or Medicaid/self-pay, Black patients were less likely than were White patients to undergo repair (Medicare, 64% vs 72%; P = .001; Medicaid/self-pay, 43% vs 61%; P = .031). Patients with Medicaid/self-pay were also less likely to undergo repair than were patients of the same race with either Medicare or private insurance (P < .05).

CONCLUSIONS

We found that Black patients with rAAAs are poorly served by the current systems of interhospital transfer in the United States, because they less often undergo transfer before repair. Although the postoperative outcomes appeared similar, this finding could be falsely optimistic, because Black patients, especially the underinsured, were turned down for repair more often even after adjustment. Significant work is needed to better understand the reasons underlying these disparities and identify the targets to improve the care of Black patients with rAAAs.

Socioeconomic disparities in abdominal aortic aneurysm repair rates and survival

BACKGROUND

Abdominal aortic aneurysm (AAA) is more prevalent in socioeconomically disadvantaged areas. This study investigated socioeconomic disparities in AAA repair rates and survival.

METHODS

The study used ecological and cohort study designs, from 31 672 census areas in England (April 2006 to March 2018), the Index of Multiple Deprivation 2010 as the area-level deprivation indicator, and Poisson, logistic and Cox regression.

RESULTS

Some 77 606 patients (83.4 per cent men) in four age categories (55-64, 65-74, 75-84, 85 or more years) were admitted with AAA from a population aged at least 55 years of 14.7 million. Elective open and endovascular repair rates were 41 (95 per cent c.i. 23 to 61) and 60 (36 to 89) per cent higher respectively among men aged 55-64 years in the most versus least deprived areas by quintile. This differences diminished and appeared to reverse with increasing age, with 26 (-1 to 45) and 25 (13 to 35) per cent lower rates respectively in men aged 85 years or more in the most deprived areas. Men admitted from more deprived areas were more likely to die in hospital without aneurysm repair. Among those who had aneurysm repair, this was more likely to be for a ruptured aneurysm than among men from less deprived areas. For intact aneurysm repair, they were relatively more likely to have this during an emergency admission. The mortality rate after repair was higher for men from more deprived areas, although the hazard diminished with age. Patterns were unclear for women.

CONCLUSION

There were clear socioeconomic disparities in operation rates, mode of presentation, and outcome for AAA surgery. Policies are needed to address these disparities.

A national evaluation of emergency department thoracotomy practices: Will a high-risk, low-yield procedure reveal potential management practice bias?

BACKGROUND

Emergency department thoracotomy is often performed on patients in extremis from traumatic exsanguination. Thus, inherent biases may play a role in whether or not the emergency department thoracotomy is performed. We aimed to investigate race, socioeconomic status, and gender disparities in the use of emergency department thoracotomy and to investigate outcomes of these patients to assess for possible surgeon practice bias.

METHOD

A nationwide retrospective cohort analysis of the American College of Surgeons Trauma Quality Programs Participant Use Profile 2016-2018. Adult patients who suffered blunt, penetrating, or other injuries secondary to falls/firearms/motor vehicle collision/other mechanisms of injury and presented to a trauma center pulseless, with or without signs of life after injury. Rates of thoracotomy, time to thoracotomy, transfer to operating room, emergency department disposition, intensive care unit length of stay, hospital length of stay, complications, mortality, and hospital disposition. Univariate analyses and adjusted multivariable regression were performed to account for confounders with significance defined as P < .05.

RESULTS

A total of 6,453 patients were analyzed. Emergency department thoracotomy and mortality were significantly higher in minorities and uninsured patients, even after risk adjustment. There were no differences in timing among race groups to emergency department thoracotomy. White/Caucasian patients experienced the highest rate of emergency department initial disposition to the intensive care unit (10.3%, P < .0001) and lowest mortality rate (89.2%, P < .0001).

CONCLUSION

Surgeon bias was not seen in the practice of emergency department thoracotomy for patients arriving pulseless. However, poorer outcomes were associated with minorities and lower socioeconomic status patients. Thoracotomy rates were higher in minorities and lower socioeconomic status patients due to more penetrating trauma.

Health Disparities Attributed to Medicare-Medicaid Dual-Eligible Status in Patients with Peripheral Arterial Disease

OBJECTIVE

Peripheral arterial disease (PAD) is a prevalent and debilitating disease that can be effectively treated by surgical revascularization. However, Medicare-Medicaid dual-eligible patients experience worse long-term outcomes, notably higher rates of amputation and mortality, relative to other insurance groups. This study aims to investigate how insurance status may perpetuate health disparities in PAD outcomes.

METHODS

The National Inpatient Sample was queried from 2000 to 2011 for patients ≥18 years with PAD who underwent surgical revascularization with hospitalization. Patients were stratified by insurance, and dual-eligibles were compared to Medicare-only, Medicaid-only, private insurance, and self-pay patients. Multivariable regression analysis was performed to assess the effect of dual-eligible status on postoperative outcomes such as inpatient mortality, complications, and favorable discharge (home or home with services).

RESULTS

A total of 771,790 hospitalizations were included in the analysis and stratified according to insurance type. Dual-eligible patients had the highest rates of major (32%) and extreme (11%) severity of illness and the highest rates of major (19%) and extreme (6%) risk of mortality among all insurance groups (p<0.001). Dual-eligibility status was independently associated with reduced odds of favorable discharge relative to all patients (p<0.001) and increased length of stay relative to Medicare-only (p=0.002) and private-payor groups (p<0.001). While dual-eligible patients had increased mortality odds relative to Medicaid-only and self-pay groups, they did not have significantly different odds of perioperative complications relative to all other insurance groups.

CONCLUSIONS

Medicare-Medicaid dual-eligible patients with PAD had more severe clinical presentations, a greater risk of extended hospitalizations, and a lower likelihood of being discharged home, relative to patients without dual-eligibility. Further studies are needed to examine the link between discharge disposition and disparities in health outcomes, as well as investigate interventions that effectively address the increased severity of PAD in dual-eligible patients.

The impact of payer status on hospital admissions: evidence from an academic medical center

Background

There are plenty of studies investigating the disparity of payer status in accessing to care. However, most studies are either disease-specific or cohort-specific. Quantifying the disparity from the level of facility through a large controlled study are rare. This study aims to examine how the payer status affects patient hospitalization from the perspective of a facility.

Methods

We extracted all patients with visiting record in a medical center between 5/1/2009-4/30/2014, and then linked the outpatient and inpatient records three year before target admission time to patients. We conduct a retrospective observational study using a conditional logistic regression methodology. To control the illness of patients with different diseases in training the model, we construct a three-dimension variable with data stratification technology. The model is validated on a dataset distinct from the one used for training.

Results

Patients covered by private insurance or uninsured are less likely to be hospitalized than patients insured by government. For uninsured patients, inequity in access to hospitalization is observed. The value of standardized coefficients indicates that government-sponsored insurance has the greatest impact on improving patients’ hospitalization.

Conclusion

Attention is needed on improving the access to care for uninsured patients. Also, basic preventive care services should be enhanced, especially for people insured by government. The findings can serve as a baseline from which to measure the anticipated effect of measures to reduce disparity of payer status in hospitalization.

Supplementary Information

The online version contains supplementary material available at (10.1186/s12913-021-06886-3).

Association of Cost Sharing With Delayed and Complicated Presentation of Acute Appendicitis or Diverticulitis

Question

Does an association exist between high cost-sharing insurance plans and patient presentation with and surgical management of acute appendicitis or acute diverticulitis?

Findings

In this cohort study of 151 852 patients, higher patient cost sharing was associated with lower odds of presenting with early, uncomplicated disease, receiving optimal surgical care, and receiving minimally invasive surgery.

Meaning

Policymakers should be aware of the clinical and financial implications of patient health care behaviors associated with increased cost sharing.

Importance

Treatment delays are associated with increased morbidity and cost of disease, although the extent to which cost sharing influences timely presentation and management of acute surgical disease remains unknown. Given recent policy changes using cost sharing to modify health care behavior, this study examines the association of cost sharing with the health of the patient at presentation and with receipt of optimal or minimally invasive surgery.

Objective

To assess whether cost sharing is associated with the likelihood of early, uncomplicated patient presentation or with surgical management of 2 representative emergency general surgery diagnoses: acute appendicitis and acute diverticulitis.

Design, Setting, and Participants

This cohort study used Health Care Cost Institute claims from January 1, 2013, through December 31, 2017, to analyze data of commercially insured individuals hospitalized for acute appendicitis or diverticulitis. In total, 151 852 patients in the data set aged 18 to 64 years and presenting with acute appendicitis or diverticulitis were included as identified using the International Classification of Diseases, Ninth Revision and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Data were analyzed from January 2020 through February 2021.

Exposures

The primary exposure was patient total cost sharing incurred for the index hospitalization, defined as their summed deductible, copayments, and coinsurance.

Main Outcomes and Measures

The primary outcome was early, uncomplicated disease presentation. Secondary outcomes were receipt of optimal surgical care and minimally invasive surgery if undergoing an operation. Analyses were conducted with multivariable logistic regression models to adjust for patient characteristics and community-level socioeconomic and geographic factors. High cost sharing was defined as quartile 4 (>$3082), and low cost sharing as quartile 1 ($0-$502).

Results

Among 151 852 patients, 52.4% were men, and the total cost-sharing median was $1725 (interquartile range, $503-$3082). Higher cost sharing was associated with lower odds of early, uncomplicated disease presentation (odds ratio, 0.63; 95% CI, 0.61-0.65). Patients with higher cost sharing were less likely to receive optimal surgical care (odds ratio, 0.96; 95% CI, 0.93-0.99) or minimally invasive surgery (odds ratio, 0.89; 95% CI, 0.84-0.95).

Conclusions and Relevance

The findings of this cohort study suggest that, as policymakers debate the degree of cost sharing in public and private insurance plans, attention should be given to the clinical and financial implications associated with care delays.

Factors Associated With State-Specific Medicaid Expansion and Receipt of Autologous Breast Reconstruction Among Patients Undergoing Mastectomy

IMPORTANCE

Despite demonstrated psychosocial benefits, autologous breast reconstruction remains underutilized. An analysis of the association between Medicaid expansion and autologous breast reconstruction has yet to be performed.

OBJECTIVE

To compare autologous breast reconstruction rates and determine the association between Medicaid expansion and breast reconstruction.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cross-sectional study was performed using the State Inpatient Database from January 1, 2012, through September 30, 2015, and included 51 340 patients. Patients were identified using the International Classification of Diseases, Ninth Revision, codes for breast cancer, mastectomy, and autologous breast reconstruction. Data from states that expanded Medicaid (New Jersey, New York, and Washington) were compared with states that did not expand Medicaid (Florida, North Carolina, and Wisconsin). Data were analyzed from June 1, 2020, through February 28, 2021.

EXPOSURES

The Patient Protection and Affordable Care Act's Medicaid expansion was implemented in 2014; the preexpansion period ranged from 2012 to 2013 (2 years), whereas the postexpansion period ranged from 2014 to 2015 quarter 3 (1.75 years).

MAIN OUTCOMES AND MEASURES

Primary outcomes included use of autologous breast reconstruction before and after expansion. Independent covariates included patient demographics, comorbidities, and state of residence.

RESULTS

Among 45 850 patients who underwent mastectomy and 9215 patients who received autologous breast reconstruction, 36 777 (67%) were White and 32 205 (59%) had private insurance. The use of immediate or delayed autologous reconstruction increased from 18.1% (4951 of 27 290) to 23.0% (4264 of 18 560) throughout the study period. Compared with 2012, the odds of reconstruction were 64% higher in 2015 (odds ratio [OR], 1.64; 95% CI, 1.48-1.80; P < .001). African American (OR, 1.43; 95% CI, 1.33-1.55; P < .001) and Hispanic (OR, 1.44; 95% CI, 1.31-1.60; P < .001) patients had higher odds of reconstruction compared with White patients regardless of state of residence. However, Medicaid expansion was associated with a 28% decrease in the odds of reconstruction (OR, 0.72; 95% CI, 0.61-0.87; P < .001) for African American patients, a 40% decrease (OR, 0.60; 95% CI, 0.50-0.74; P < .001) for Hispanic patients, and 20% decrease (OR, 0.80; 95% CI, 0.67-0.96; P = .01) for patients with Asian, Native American, or other minority race/ethnicity. Medicaid expansion was not associated with changes in the odds of reconstruction for White patients.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, although the odds of receiving autologous breast reconstruction increased annually, Medicaid expansion was associated with decreased odds of reconstruction for African American patients, Hispanic patients, and other patients of color.

Use of Flap Salvage for Lower Extremity Chronic Wounds Occurs Most Often in Competitive Hospital Markets

Wounds in the comorbid population require limb salvage to prevent amputation. Extensive health economics literature demonstrates that hospital activities are influenced by level of market concentration. The impact of competition and market concentration on limb salvage remains to be determined.

Methods

Admissions for chronic lower extremity wounds in nonrural hospitals were identified in the 2010-2011 National Inpatient Survey using ICD-9-CM diagnosis codes. The study cohort consisted of admitted patients receiving amputations, salvage without flap techniques (eg, skin grafts), or salvage with flap techniques. The all-service Herfindahl-Hirschman Index (HHI), which is a commonly used tool for market and antitrust analyses, was used to measure hospital competition. Multinomial regression analysis accounting for the complex survey design of the NIS was used to determine the relationship between the HHI and hospital adoption of limb salvage controlling for patient, hospital, and market factors.

Results

The study cohort represents 124,836 admissions nationally: 89,880 amputations, 26,715 salvage without flap techniques, and 8241 salvage flap techniques. Diabetics accounted for 64.1% of all study admissions. Hospitals in highly competitive markets performed more flaps for chronic lower extremity wounds than noncompetitive markets. Controlling for other factors, hospitals in highly competitive markets, relative to those in highly concentrated markets, were 2.48 percentage points more likely to perform limb salvage with flaps (P < 0.01). Other factors were less predictive.

Conclusion

Increased hospital competition is the strongest systems-level predictor of receipt of lower extremity flaps among patients with chronic wounds. Improving access to reconstructive limb services must consider the competitive structure of hospital markets.

Disparities in Lupus and Lupus Nephritis Care and Outcomes Among US Medicaid Beneficiaries

Systemic lupus erythematosus (SLE) is a serious chronic autoimmune disease with substantial morbidity and mortality. Although improved diagnostics and therapeutics have contributed to declining mortality rates, important disparities exist in SLE survival rates by race, ethnicity, gender, age, country, and social disadvantage. This review highlights the burden of SLE and lupus nephritis among Medicaid beneficiaries, outlines barriers in access to high-quality SLE care and medication adherence in the Medicaid SLE population, and summarizes disparities in adverse outcomes among SLE patients enrolled in Medicaid.

Impact of Geographic Socioeconomic Disadvantage on Minor Amputation Outcomes in Patients With Diabetes

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.

Lower Extremity Revascularization for Chronic Limb-Threatening Ischemia among Patients at the Extremes of Age

BACKGROUND

Patients with chronic limb-threatening ischemia (CLTI) at the extremes of age are thought to have distinct risk factor profiles and poor outcomes after lower extremity revascularization (LER). The aim of this study is to examine the relationships among age, risk factor profiles, and outcomes of LER in patients with CLTI in a large database focusing on the extreme age groups.

METHODS

Patients undergoing LER for CLTI in the Vascular Quality Initiative suprainguinal bypass, infrainguinal bypass, and peripheral vascular intervention files were reviewed through 2019. Patients were stratified into 3 groups: premature peripheral artery disease (PAD) (≤50 years old), 51-84 years old, and elderly (≥85 years old). Trends in major amputation and mortality by age group were analyzed.

RESULTS

There were 156,513 patients who underwent LER for CLTI. Of these, 9,063 (5.79%) patients had premature PAD, 131,694 (84.14%) patients were 51-84 years old, and 15,756 (10.07%) were elderly. Patients with premature PAD were more likely to have insulin-dependent diabetes, be dialysis-dependent, and be active smokers compared to patients 51-84 years old and the elderly. Elderly patients were more likely to undergo an endovascular procedure for tissue loss compared to younger groups. Perioperative and 1-year major amputation rates were highest among patients with premature PAD and decreased with increasing age (P < 0.001), while perioperative and 1-year mortality increased with age (P < 0.001). On multivariable analysis, premature PAD was associated with an increased risk of major amputation (odds ratio, OR = 1.41 [1.22-1.62]), while elderly age was associated with decreased odds of major amputation compared to patients 51-84 years old (OR = 0.61 [0.51-0.73]).

CONCLUSIONS

Patients at the extremes of age have significantly different outcomes after LER for CLTI. Although mortality increases with age, the risk of major amputation decreases. Patients with premature PAD constitute a group of patients with a high risk of perioperative and 1-year major amputation.

Outcomes of a 12-month patient-centred medical home model in improving patient activation and self-management behaviours among primary care patients presenting with chronic diseases in Sydney, Australia: a before-and-after study

BACKGROUND

Studies report that increased levels of patient activation is associated with increased engagement with the health care system, better adherence to treatment protocols, and improved health outcomes. This study aims to evaluate the outcomes of a 12-month Patient-Centred Medical Home (PCMH) model called 'WellNet' on the activation levels of patients with one or more chronic diseases in general practices across Northern Sydney, Australia.

METHODS

A total of 636 patients aged 40 years and above with one or more chronic conditions consented to participate in the WellNet program which was delivered across six general practices in Northern Sydney, Australia. The WellNet intervention includes team-based care with general physicians and trained chronic disease management care coordinators collaborating with patients in designing a patient-tailored care plan with improved self-management support and care navigation according to the level of risk and health care needs. The level of patient activation was measured using the validated PAM 13-item scale at baseline and follow-up. A before and after case-series design was employed to determine the adjusted mean differences between baseline and 12-months using repeated measures analysis of covariance (ANCOVA). Additionally, the backward stepwise multivariable regression models were employed to identify significant predictors of activation at follow-up.

RESULTS

Of the 626 patients, 420 reported their PAM scores at follow-up. The mean (SD) baseline PAM score was 57.9 (13.0). The adjusted model showed significant mean difference in PAM scores by increase of 6.5 (95% CI 5.0-8.1; p-value< 0.001) after controlling for baseline covariates. The multivariable regression models showed that older age (B = - 0.14; 95% CI -0.28, - 0.01) and private insurance (uninsured patients) (B = - 3.41; 95% CI -6.50, - 0.32) were significantly associated with lower PAM scores at 12 months whereas higher baseline PAM score (B = 0.48; 95% CI 0.37, 0.59) was significantly associated with higher follow-up PAM score.

CONCLUSION

The WellNet study is the first of its kind in Australia to report on changes in the patient activation levels among patients with one or more chronic diseases. PCMH has the potential to improve patient activation and engagement which can lead to long-term health benefits and sustained self-management behaviours.

A National Analysis of Traumatic Thoracic Aortic Repair: Does Insurance Status Matter?

BACKGROUND

Traumatic thoracic aortic injuries (TAIs) carry a substantial mortality. Our study aim was to evaluate the impact of insurance status on outcomes in severely injured trauma patients after either thoracic endovascular aortic repair (TEVAR) or open repair using the National Trauma Data Bank Research Data Set (NTDB-RDS).

METHODS

The NTDB-RDS was reviewed for outcomes in severely injured patients and TAI repair method (TEVAR vs open). Patients were divided into insured (Medicaid, Medicare, private insurance) and uninsured (self-pay) status groups. Patients were further divided by injury severity score (ISS) of 15-24 and ≥25 to adjust for injury burden. Demographic characteristics and outcome measures were compared. Chi-square, t-test, and analysis of variance were used with significance defined as P < .05.

RESULTS

Within the NTDB-RDS, a review of nearly 1 million patients led to 241 that underwent repair for TAI and had insurance status and repair type documented. 88.8% (214/241) of patients were insured, while 11.2% (27/241) of patients were uninsured. There were no significant differences in repair type based on insurance status. For open repair with an ISS ≥25, mortality was significantly higher in the uninsured group compared with insured (55.5% vs 21.9%, P = .001).

CONCLUSION

For open repair in patients with TAI and high injury burden, uninsured status was associated with a significant increase in mortality rate compared with insured patients. Future studies should investigate the effect of insurance type on TAI outcomes and causes of higher mortality in uninsured patients.

Sjogren's syndrome is associated with higher rate of non-home discharge after primary hip arthroplasty and higher transfusion rates after primary hip or knee arthroplasty: a U.S. cohort study

Background

To assess whether Sjogren’s Syndrome (SS) is associated with outcomes after total knee or hip arthroplasty (TKA/THA).

Methods

We used the 1998–2014 U.S. National Inpatient Sample data. We performed multivariable-adjusted logistic regression analyses to assess the association of SS with healthcare utilization (hospital charges, length of hospital stay, discharge to non-home setting), and in-hospital complications (implant infection, revision, transfusion, mortality), controlling for important covariates and confounders. In sensitivity analyses, we additionally adjusted the main models for hospital location/teaching status, bed size, and region.

Results

We examined 4,116,485 primary THAs and 8,127,282 primary TKAs performed from 1998 to 2014; 12,772 (0.2%) primary TKAs and 6222 (0.2%) primary THAs were done in people with SS. In multivariable-adjusted models, SS was associated with a statistically significant higher odds ratio (OR; 95% confidence interval (CI)) of discharge to a rehabilitation/inpatient facility post-THA, 1.13 (1.00, 1.28), but not post-TKA, 0.93 (0.86, 1.02). We noted no differences in the length of hospital stay or hospital charges. SS was associated with significantly higher adjusted odds of in-hospital transfusion post-THA, 1.37 (1.22, 1.55) and post-TKA, 1.21 (1.10, 1.34). No significant differences by SS diagnosis were seen in hospital stay, hospital charges implant infection, implant revision or mortality rates.

Conclusions

People with SS had higher transfusion rate post-TKA/THA, and higher rate of discharge to non-home setting post-THA. The lack of association of SS with post-arthroplasty complications should reassure patients, surgeons and policy-makers about the utility of TKA/THA in people with SS undergoing these procedures.

Impact of insurance on hospital course and readmission after resection of benign meningioma

INTRODUCTION

Surgical outcomes and healthcare utilization have been shown to vary based on patient insurance status. We analyzed whether patients' insurance affects case urgency for and readmission after craniotomy for meningioma resection, using benign meningioma as a model system to minimize confounding from the disease-related characteristics of other neurosurgical pathologies.

METHODS

We analyzed 90-day readmission for patients who underwent resection of a benign meningioma in the Nationwide Readmission Database from 2014-2015.

RESULTS

A total of 9783 meningioma patients with private insurance (46%), Medicare (39%), Medicaid (10%), self-pay (2%), or another scheme (3%) were analyzed. 72% of all cases were elective; with 78% of cases in privately insured patients being elective compared to 71% of Medicare (p > 0.05), 59% of Medicaid patients (OR 2.3, p < 0.001), and 49% of self-pay patients (OR 3.4, p < 0.001). Medicare (OR 1.5, p = 0.002) and Medicaid (OR 1.4, p = 0.035) were both associated with higher likelihood of 90-day readmission compared to private insurance. In comparison, 30-day analyses did not unveil this discrepancy between Medicaid and privately insured, highlighting the merit for longer-term outcomes analyses in value-based care. Patients readmitted within 30 days versus those with later readmissions possessed different characteristics.

CONCLUSIONS

Compared to patients with private insurance coverage, Medicaid and self-pay patients were significantly more likely to undergo non-elective resection of benign meningioma. Medicaid and Medicare insurance were associated with a higher likelihood of 90-day readmission; only Medicare was significant at 30 days. Both 30 and 90-day outcomes merit consideration given differences in readmitted populations.

Disparities in mortality after abdominal aortic aneurysm repair are linked to insurance status

OBJECTIVE

The objective of this study was to determine differences in mortality after abdominal aortic aneurysm (AAA) repair based on insurance type.

METHODS

In this retrospective cohort study, data from all-payer patients in nonpsychiatric hospitals in New York, Maryland, Florida, Kentucky, and California from January 2007 to December 2014 (excluding California, ending December 2011) were extracted from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. There were 90,102 patients ≥18 years old with available insurance data who underwent open AAA repair or endovascular aneurysm repair (EVAR) identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes 3844, 3925, and 3971. EVAR patients were identified using the procedure code 3971, and the remainder of cases were categorized as open. Patients were divided into cohorts by insurance type as Medicare, Medicaid, uninsured (self-pay/no charge), other, or private insurance. Patients were further stratified for subgroup analyses by procedure type. Unadjusted rates of in-hospital mortality, the primary outcome, as well as secondary outcomes, such as surgical urgency, 30-day and 90-day readmissions, length of stay, total charges, and postoperative complications, were examined by insurance type. Adjusted odds ratios (ORs) for in-hospital mortality were calculated using multivariate logistic regression models fitted to the data. The multivariate models included patient-, surgical-, and hospital-specific factors with bivariate baseline testing suggestive of association with insurance status in addition to variables that were selected a priori.

RESULTS

Medicaid and uninsured patients had the highest rates of mortality relative to private insurance beneficiaries in all cohorts. Medicaid patients incurred a 47% increase in the odds of mortality, the highest among the insured, after all AAA repairs (OR, 1.47; 95% confidence interval [CI], 1.23-1.76), whereas uninsured patients experienced a 102% increase in the odds of mortality (OR, 2.02; 95% CI, 1.54-2.67). Subgroup analyses for open AAA repair and EVAR corroborated that Medicaid insurance (open repair OR, 1.37 [95% CI, 1.14-1.64]; EVAR OR, 2.06 [95% CI, 1.40-3.04]) and uninsured status (open repair OR, 1.85 [95% CI, 1.35-2.54]; EVAR OR, 2.96 [95% CI, 1.82-4.81]) were associated with the highest odds of mortality after both procedures separately.

CONCLUSIONS

This study demonstrates that Medicaid insurance and uninsured status are associated with higher unadjusted rates and adjusted ORs for in-hospital mortality after AAA repair relative to private insurance status. Primary payer status therefore serves as an independent predictor of the risk of death subsequent to AAA surgical interventions.

The Impact of the Affordable Care Act Medicaid Expansion on Vascular Surgery

BACKGROUND

The Affordable Care Act (ACA) Medicaid expansion increased Medicaid eligibility such that all adults with an income level up to 138% of the federal poverty threshold in 2014 qualified for Medicaid benefits. Prior studies have shown that the ACA Medicaid expansion was associated with increased access to care. The impact of the ACA Medicaid expansion on patients undergoing complex care for major vascular pathology has not been evaluated.

METHODS

The Healthcare Cost and Utilization Project State Inpatient Database was used to identify patients undergoing care for major vascular pathology in 6 states from 2010 to 2014. The analysis cohort included adult patients between the ages of 18 and 64 years who underwent a nonemergent surgical procedure for an abdominal aortic aneurysm, thoracic aortic aneurysm, carotid artery stenosis, peripheral vascular disease, or chronic kidney disease. Poisson regression was used to determine the incidence rate ratios (IRRs).

RESULTS

There were a total of 83,960 patients in the study cohort. Compared with nonexpansion states, inpatient admissions for Medicaid patients with an abdominal or thoracic aneurysm and carotid stenosis diagnosis increased significantly (IRR, 1.20, 1.27, 1.06, respectively; P < 0.05) in states that expanded Medicaid. Vascular-related surgeries increased for carotid endarterectomy, lower extremity revascularization, lower extremity amputation, and arteriovenous fistula in expansion states (IRR, 1.24, 1.10, 1.11, 1.16, respectively; P < 0.05) compared with nonexpansion states.

CONCLUSIONS

In states that expanded Medicaid coverage under the ACA, the rate of vascular-related surgeries and admissions for Medicaid patients increased. We conclude that expanding insurance coverage results in enhanced access to vascular surgery.

Polymyositis has minimal effect on primary total knee or hip arthroplasty outcomes

To assess whether polymyositis is associated with more complications and higher healthcare utilization after total knee or hip arthroplasty (TKA/THA). Using the 1998-2014 U.S. National Inpatient Sample data, we performed multivariable-adjusted logistic regression analyses to assess the association of polymyositis with in-hospital complications (implant infection, revision, transfusion, mortality) and healthcare utilization (hospital charges, length of hospital stay, discharge to non-home setting), controlling for important covariates and confounders. Sensitivity analyses additionally adjusted the main models for hospital location/teaching status, bed size, and region. Of the 4,116,485 THAs and 8,127,282 TKAs, 853 people with polymyositis had THAs (0.02%) and 1038 had TKAs (0.01%). In multivariable-adjusted analyses, compared to people without polymyositis, people with polymyositis had similar odds of hospital charges above the median, hospital stay > 3 days, and discharge to non-home setting post-TKA and post-THA. Polymyositis was associated with significantly lower odds ratio (OR; 95% confidence interval [CI]) of revision and mortality post-THA, 0.44 (0.36, 0.55) and 0.63 (0.48, 0.84), but not post-TKA, 2.98 (0.47, 18.95) and 4.40 (0.61, 31.64), respectively. Findings from the main analyses were confirmed in the sensitivity analyses. People with polymyositis had no increase in healthcare utilization post-TKA/THA. A lower revision rate and mortality post-THA in people with polymyositis need further confirmation. Study findings should reassure the key stakeholders about the benefits of TKA/THA, including people with polymyositis.

Comparing Standard Performance and Outcome Measures in Hospitalized Pituitary Tumor Patients with Secretory versus Nonsecretory Tumors

BACKGROUND

Patient safety indicators (PSIs) and hospital-acquired conditions (HACs) are reported quality measures. We compared their prevalence in patients with secretory and nonsecretory pituitary adenoma using the National (Nationwide) Inpatient Sample (NIS), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.

METHODS

The NIS was queried for hospitalizations 2002-2014 involving pituitary adenomas. Prevalence of PSI, HAC, and 9 pituitary-related complications was determined using International Classification of Diseases, Ninth Revision codes. Patient risk factors were evaluated through multivariate analysis.

RESULTS

A total of 20,743 patients with nonsecretory tumor and 3385 patients with secretory tumor were identified. Among patients with nonsecretory tumor, 3.79% experienced any PSI or HAC. Of patients with secretory tumor, 2.54% had any PSI or HAC. Before adjusting for covariation, secretory patients were less likely to have any PSI or HAC (odds ratio [OR], 0.652; P = 0.0002), experience any pituitary-related complication (OR, 0.804; P < 0.0001), have a poor outcome (hazard ratio [HR], 0.435; P < 0.0001), and die during hospitalization (HR, 0.293; P = 0.0015). Secretory patients had significantly shorter mean hospital length of stay (secretory/nonsecretory percent difference, -11.95%; P < 0.0001). However, inverse propensity score-weighted ORs comparing the groups' outcomes showed that there was no significant difference in the prevalence of any PSIs and HACs (OR, 0.963; P = 0.8570), pituitary-related complications (OR, 0.894; P = 0.1321), poor outcomes (HR, 0.990; P = 0.9287), in-hospital death (HR, 0.663; P = 0.2967), and length of stay (percent difference, -2.31%; P = 0.2967) between groups.

CONCLUSIONS

Lack of significant difference in outcome measures after controlling for covariation is consistent with our finding that patients with nonsecretory tumor have more comorbidities on presentation for treatment. PSIs and HACs have limited ability to measure complications specific to pituitary tumors.

Financial barriers in accessing medical care for peripheral artery disease are associated with delay of presentation and adverse health status outcomes in the United States

Patient-reported difficulties in affording health care and their association with health status outcomes in peripheral artery disease (PAD) have never been studied. We sought to determine whether financial barriers affected PAD symptoms at presentation, treatment patterns, and patient-reported health status in the year following presentation. A total of 797 United States (US) patients with PAD were identified from the Patient-centered Outcomes Related to TReatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) study, a prospective, multicenter registry of patients presenting to vascular specialty clinics with PAD. Financial barriers were defined as a composite of no insurance and underinsurance. Disease-specific health status was measured by Peripheral Artery Questionnaire (PAQ) and general health-related quality of life was measured by EuroQol 5 (EQ5D) dimensions at presentation and at 3, 6, and 12 months of follow-up. Among 797 US patients, 21% (n = 165) of patients reported financial barriers. Patients with financial barriers presented at an earlier age (64 ± 9.5 vs 70 ± 9.4 years), with longer duration of symptoms (59% vs 49%) (all p ⩽ 0.05), were more depressed and had higher levels of perceived stress and anxiety. After multivariable adjustment, health status was worse at presentation in patients with financial barriers (PAQ: -7.0 [-10.7, -3.4]; p < 0.001 and EQ5D: -9.2 [-12.74, -5.8]; p < 0.001) as well as through 12 months of follow-up (PAQ: -8.4 [-13.0, -3.8]; p < 0.001 and EQ5D: -9.7 [-13.2, -6.2]; p < 0.001). In conclusion, financial barriers are associated with later presentation as well as poorer health status at presentation and at 12 months. ClinicalTrials.gov Identifier: NCT01419080.

Systemic sclerosis is associated with knee arthroplasty outcomes: a National US study

OBJECTIVE

To assess whether systemic sclerosis (SSc) is associated with total knee arthroplasty (TKA) outcomes.

METHODS

We used the 1998-2014 US National Inpatient Sample. We conducted multivariable-adjusted logistic regression analyses to examine the association of a diagnosis of SSc with post-TKA in-hospital complications (implant infection, revision, transfusion, mortality) and healthcare utilization (hospital charges, hospital stay, non-home vs. home discharge). Odds ratios (OR) and 95 % confidence intervals (CI) were calculated.

RESULTS

Our cohort included 8,123,388 people without SSc and 3894 people with SSc. In multivariable-adjusted analyses, compared to people without SSc, people with SSc had higher odds of transfusion, hospital stay > 3 days and non-home discharge with higher OR of 1.42 (95 % CI, 1.20, 1.69), 1.29 (95 % CI, 1.11, 1.49), and 1.29 (95 % CI, 1.11, 1.49), respectively. No differences were seen in revision, 0.68 (95 % CI, 0.10, 4.69) or hospital charges above the median, 1.01 (95 % CI, 0.70, 1.46). Differences in implant infection or mortality were not estimable, since none of the patients with SSc had implant infection or died. Sensitivity analyses that adjusted the main analysis additionally for hospital-level variables confirmed study findings with minimal or no attenuation of OR.

CONCLUSION

SSc was associated with higher risk of transfusion and increased healthcare utilization after TKA. Future studies should examine if interventions can address modifiable factors to further optimize these outcomes.Key Points• Systemic sclerosis was independently associated with higher healthcare utilization after TKA.• The adjusted odds of transfusion was higher in people with systemic sclerosis compared to those without systemic sclerosis who underwent TKA.

Association of health insurance with post-resuscitation care and neurological outcomes after return of spontaneous circulation in out-of-hospital cardiac arrest patients in Korea

BACKGROUND

We investigated the association of health insurance status with post-resuscitation care and neurological recovery in out-of-hospital cardiac arrest (OHCA) and whether the effects changed with age or gender.

METHODS

Adult OHCAs with presumed cardiac etiology who had sustained ROSC from 2013 to 2016 were enrolled from the nationwide OHCA registry of Korea. Insurance status was categorized into 2 groups: National Health Insurance (NHI) and Medical Aid (MA). The endpoints were post-resuscitation coronary reperfusion therapy (CRT), targeted temperature management (TTM), and good neurological recovery (cerebral performance category of 1 or 2). Multivariable logistic regression models and interaction analyses (insurance × age and insurance × gender) were conducted for adjusted odds ratios (aORs) and 95% confidence intervals (CI).

RESULTS

Of a total of 19,865 eligible OHCA patients, 18,119 (91.2%) were covered by NHI and 1746 (8.8%) by MA. The MA group was less likely to receive post-resuscitation CRT and TTM (aOR (95% CI): 0.75 (0.59-0.96) for CRT; 0.71 (0.57-0.89) for TTM) and had worse neurological outcomes (0.71 (0.57-0.89)) compared with the NHI group. In the interaction analyses, MA was associated with less CRT and good neurological recovery in the 45-64 year old group (0.54 (0.37-0.77) for CRT; 0.70 (0.51-0.95) for neurological outcome) and in the male group (0.69 (0.52-0.91) for CRT; 0.77 (0.61-0.97) for TTM; 0.70 (0.53-0.92)) for neurological outcome).

CONCLUSIONS

There were disparities in post-resuscitation care and substantial neurological recovery by health insurance status, and the disparities were prominent in middle-aged adults and males. Increasing health insurance coverage for post-resuscitation care should be considered.

Evolving Trends in Insurance Coverage of Vascular Surgery Patients in Academic Practice

BACKGROUND

Insurance coverage of vascular surgery patients may differ from patients with less chronic surgical pathologies. The goal of this study is to identify trends in insurance status of vascular surgery patients over the last 10 years at a busy academic center.

METHODS

All consecutive patient visits for a vascular procedure from 2006 to 2016 were retrospectively reviewed from a prospectively collected institutional database. Data points included insurance status, procedures performed, and date of admission. The insurance status was categorized as Medicare, Medicaid, and uninsured. Samples were divided between 2006-2009 and 2011-2016 for comparison. Unpaired t-test, chi-squared test, and regression analysis were used to determine significant trends over the study period.

RESULTS

From 2006 to 2016, 6,007 vascular surgery procedures were performed. Procedure volume increased significantly from 1,309 to 4,698 between the 2 timeframes (P < 0.05), whereas the percentage of Medicaid and Medicare patients trended upward but did not achieve significance. There was a significant decrease in the percentage of uninsured patients between the cohorts (5.65% vs. 2.96%, P < 0.05). In 2012, 10.14% of patients were uninsured compared with 2.56% in 2016 (P < 0.05).

CONCLUSIONS

Insurance status affects access to care and subsequent outcomes. In our busy academic center, insurance coverage for vascular surgery has significantly increased over the past decade. The number of Medicaid and Medicare patients has slowly increased, but a significant and continuing decline in uninsured patients was observed. Implementation of the Affordable Care Act during this time period may have played a role in providing coverage for patient needing vascular surgery.

The influence of payor status on outcomes associated with surgical repair of upper gastrointestinal perforations due to peptic ulcer disease in the United States

BACKGROUND

An association between lack of insurance and inferior outcomes has been well described for a number of surgical emergencies, yet little is known about the relationship of payor status and outcomes of patients undergoing emergent surgical repair for upper gastrointestinal (UGI) perforations. We evaluated the association of payor status and in-hospital mortality for patients undergoing emergency surgery for UGI perforations in the United States.

METHODS

Nationwide Inpatient Sample (NIS) was queried to identify patients between 18 and 64 years of age who underwent emergent (open or laparoscopic) repair for UGI perforations secondary to peptic ulcer disease (2010-2014). Primary outcome was in-hospital mortality. Secondary outcomes were major and minor postoperative complications. The main predictor outcome was insurance status (Private, Medicaid, Uninsured). Univariate and multivariable regression analyses were performed. Data were weighted to provide national estimates.

RESULTS

21,005 patients underwent surgical repair for UGI perforations. Patients with private insurance represented the largest payor group (47%). After adjustment of other factors, payor status was not a statistically significant predictor of in-hospital mortality (Medicaid vs. Private: [OR] 1.1; 95% [CI] 0.67-1.81; Uninsured vs. Private: OR 0.9, 95% CI 0.52-1.61). However, payor status remained a statistically significant predictor of major postoperative complications (Medicaid vs. Private [OR] 1.4; 95% CI 1.1, 1.8; Uninsured vs. Private [OR]1.2, 95% CI 0.9, 1.5) and minor postoperative complications (Medicaid vs. Private [OR] 1.4; 95% CI 1.1, 1.9; Uninsured vs. Private [OR]1.2, 95% CI 0.9, 1.6).

CONCLUSIONS

Emergency surgery for UGI perforations is associated with high mortality and morbidity across all payor classes; however, Medicaid is a predictor for both major and minor postoperative complications. Preventing perforation through preventative measures will be key to reducing the burden of peptic ulcer disease across all populations.

Understanding abdominal aortic aneurysm epidemiology: socioeconomic position affects outcome

Background

Low socioeconomic position (SEP) has been demonstrated to negatively influence outcome in several cardiovascular patient groups. The aim of this study was to analyse time trends of incidence of intact abdominal aortic aneurysm (iAAA) and ruptured AAA (rAAA), respectively, and to investigate whether SEP had any influence on the probability to present with rupture and, finally, to determine the impact of SEP on outcome.

Methods

Nationwide population-based study including all individuals with iAAA or rAAA in Sweden during 2001–2015.

Results

The number of individuals with an AAA was 41 222; the majority were identified as iAAA 33 254 (80.7%) and 7968 (19.3%) as rAAA. Time trends showed decreasing incidence of rAAA but increase in iAAA during the study period. Individuals with low income or low educational level were more likely to present with a rAAA rather than iAAA: OR 2.16 (95 % CI 1.98 to 2.36, p<0.001) and OR 1.33 (95 % CI 1.21 to 1.46, p<0.001), respectively. Low income was also associated with increased 90-day mortality and 1-year mortality after treatment for rAAA, OR 1.42 (95% CI 1.07 to 1.89, p=0.014) and OR 1.39 (95% CI 1.13 to 1.97, p=0.005).

Conclusion

This large nationwide study showed a decreasing incidence of rAAA. Individuals with low SEP were found to have an augmented risk of presenting with rAAA rather than iAAA and, in addition, to fare worse after repair. Consequently, SEP should be regarded as a relevant risk factor that should be included in considerations for improved care flow of patients with AAA.

Improved access to health care in Massachusetts after 2006 Massachusetts Healthcare Reform Law is associated with a significant decrease in mortality among vascular surgery patients

BACKGROUND

Access to medical care, by adequate insurance coverage, has a direct impact on outcomes for patients undergoing vascular procedures. We evaluated in-hospital mortality for patients undergoing index vascular procedures before and after the Massachusetts Healthcare Reform Law (MHRL) in 2006, which mandated insurance for all Massachusetts residents, both in Massachusetts and throughout the United States.

METHODS

The National Inpatient Sample was queried to identify patients undergoing interventions for peripheral arterial disease, carotid artery stenosis, and abdominal aortic aneurysms based on International Classification of Diseases, Ninth Revision, Clinical Modification procedural and diagnostic codes. The cohort was then divided into patients treated within Massachusetts (MA) and non-Massachusetts (NMA) hospitals. Two time intervals were examined: before (2003-2006, P1) and after the MHRL (2007-2011, P2). The primary outcome of interest included in-hospital mortality. Patients in MA and NMA hospitals were described in terms of demographics and presentation by time interval (P2 vs P1) compared using χ² and t-tests. Weighted logistic regression with term modeling change in the odds ratio (OR) for P2 was performed to test and to estimate trends in mortality. Time (year of procedure) and region interactions were investigated by inclusion of time-region interactions in our analyses. Subgroup analysis was performed for P2 vs P1 among nonwhite, nonelderly, and low-income patients.

RESULTS

We identified 306,438 patients who underwent repair of abdominal aortic aneurysm, lower extremity bypass, or carotid endarterectomy in MA and NMA hospitals. MA hospital patients had an increase in both Medicaid and private insurance status after the MHRL (P1 = 2.6% and 21% vs P2 = 3.3% and 21.7%, respectively; P = .034). In-hospital mortality trended down for all groups across the entire study. In comparing P2 vs P1 trends, MA hospital odds of mortality per year was lowered by 26% (OR, 0.74; 95% confidence interval [CI], 0.56-0.99; P = .042) not seen in NMA hospitals (OR, 1.03; 95% CI, 0.97-1.09; P = .405). Time and region interaction terms indicated significant time trend difference in both unadjusted (P = .031) and adjusted (P = .033) analysis in MA hospitals not observed in NMA hospitals. This pattern continued when the samples were stratified by procedure. Patients undergoing vascular procedures in MA hospitals had a significantly lowered OR of mortality, with fewer patients presenting at late disease stages in P2 vs P1. Nonelderly patients in Massachusetts, who benefit from the Medicaid expansion provided by the MHRL, had a profound 92% drop in odds of mortality in P2 vs P1 (OR, 0.08; 95% CI, 0.010-0.641; P = .017) compared with the 14% drop in NMA (OR, 0.86; 95% CI, 0.709-1.032; P = .103).

CONCLUSIONS

The 2006 MHRL is associated with a decrease in mortality for patients undergoing index vascular surgery procedures in MA compared with NMA hospitals. This study suggests that governmental policy may play a key role in positively affecting the outcomes for patients.

Insurance status and mortality among patients with AIDS

OBJECTIVES

The aim of the study was to evaluate risk factors for mortality, including health care insurance status, among patients with AIDS in the era of modern combination antiretroviral therapy (cART).

METHODS

This study was part of the prospective, multicentre, observational Longitudinal Study of the Ocular Complications of AIDS (LSOCA). Patients were classified as having private health care insurance, Medicare, Medicaid, or no insurance. Hazard ratios (HRs) for death were calculated using proportional hazards regression models and staggered entries, anchored to the AIDS diagnosis date.

RESULTS

Among 2363 participants with AIDS, 97% were treated with cART. At enrolment, 31% of participants had private insurance, 29% had Medicare, 24% had Medicaid, and 16% were uninsured. Noninfectious, age-related diseases, such as hypertension, diabetes, and renal disease, were more frequent among persons with Medicare than among those with private insurance. Compared with those who were privately insured, mortality was greater among participants with Medicare [adjusted HR (HR_adj ) 1.35; 95% confidence interval (CI) 1.08-1.67; P = 0.008]. Among participants with a suppressed HIV viral load, compared with those who were privately insured, HR_adj values for mortality were 1.93 (95% CI 1.08-3.44; P = 0.02) for those with Medicare and 2.09 (95% CI 1.02-4.27; P = 0.04) for those with Medicaid. Mortality among initially uninsured participants was not significantly different from that for privately insured participants, but these participants typically obtained ART and insurance during follow-up. Compared with privately insured participants, time-updated HR_adj values for mortality were 1.34 (95% CI 1.05-1.70; P = 0.02) for those with Medicare, 1.34 (95% CI 1.01-1.80; P = 0.05) for those with Medicaid, and 1.35 (95% CI 0.97-1.88; P = 0.05) for those who were uninsured.

CONCLUSIONS

In persons with AIDS, compared with those with private insurance, those with public insurance had increased mortality, possibly as a result of a greater burden of noninfectious, age-related diseases.