The quality of surgical care in safety net hospitals: A systematic review

Utilization of minimally invasive colectomy at safety-net hospitals in the United States

BACKGROUND

Prior literature has reported inferior surgical outcomes and reduced access to minimally invasive procedures at safety-net hospitals. However, this relationship has not yet been elucidated for elective colectomy. We sought to characterize the association between safety-net hospitals and likelihood of minimally invasive resection, perioperative outcomes, and costs.

METHODS

All adult (≥18 years) hospitalization records entailing elective colectomy were identified in the 2016-2020 National Inpatient Sample. Centers in the top quartile of safety-net burden were considered safety-net hospitals (others: non-safety-net hospitals). Multivariable regression models were developed to assess the impact of safety-net hospitals status on key outcomes.

RESULTS

Of ∼532,640 patients, 95,570 (17.9%) were treated at safety-net hospitals. The safety-net hospitals cohort was younger and more often of Black race or Hispanic ethnicity. After adjustment, care at safety-net hospitals remained independently associated with reduced odds of minimally invasive surgery (adjusted odds ratio 0.92; 95% confidence interval 0.87-0.97). The interaction between safety-net hospital status and race was significant, such that Black race remained linked with lower odds of minimally invasive surgery at safety-net hospitals (reference: White race). Additionally, safety-net hospitals was associated with greater likelihood of in-hospital mortality (adjusted odds ratio 1.34, confidence interval 1.04-1.74) and any perioperative complication (adjusted odds ratio 1.15, confidence interval 1.08-1.22), as well as increased length of stay (β+0.26 days, confidence interval 0.17-0.35) and costs (β+$2,510, confidence interval 2,020-3,000).

CONCLUSION

Care at safety-net hospitals was linked with lower odds of minimally invasive colectomy, as well as greater complications and costs. Black patients treated at safety-net hospitals demonstrated reduced likelihood of minimally invasive surgery, relative to White patients. Further investigation is needed to elucidate the root causes of these disparities in care.

Disparities in clinical trial enrollment among patients with gastrointestinal cancer relative to minority-serving and safety-netting hospitals

BACKGROUND

For results to be generalizable to all patients with cancer, clinical trials need to include a diverse patient demographic that is representative of the general population. We sought to characterize the effect of receiving care at a minority-serving hospital (MSH) and/or safety-net hospital on clinical trial enrollment among patients with gastrointestinal (GI) malignancies.

METHODS

Adult patients with GI cancer who underwent oncologic surgery and were enrolled in institutional-/National Cancer Institute-funded clinical trials between 2012 and 2019 were identified in the National Cancer Database. Multivariable regression was used to assess the relationship between MSH and safety-net status relative to clinical trial enrollment.

RESULTS

Among 1,112,594 patients, 994,598 (89.4%) were treated at a non-MSH, whereas 117,996 (10.6%) were treated at an MSH. Only 1857 patients (0.2%) were enrolled in a clinical trial; most patients received care at a non-MSH (1794 [96.6%]). On multivariable analysis, the odds of enrollment in a clinical trial were markedly lower among patients treated at an MSH vs non-MSH (odds ratio [OR], 0.32; 95% CI, 0.22-0.46). In addition, even after controlling for receipt of care at MSH, Black patients remained at lower odds of enrollment in a clinical trial than White patients (OR, 0.57; 95% CI, 0.45-0.73; both P < .05).

CONCLUSION

Overall, clinical trial participation among patients with GI cancer was extremely low. Patients treated at an MSH and high safety-net burden hospitals and Black individuals were much less likely to be enrolled in a clinical trial. Efforts should be made to improve trial enrollment and address disparities in trial representation.

Examining disparities in regional anaesthesia and pain medicine

In high-resource countries, health disparities exist in both treatment approaches and health outcomes. Race and ethnicity can serve as proxies for other socioeconomic factors and social determinants of health such as income, education, social support, and residential neighbourhood, which strongly influence health outcomes and disparities. In regional anaesthesia and pain medicine, disparities exist across several surgical specialties including obstetrics, paediatrics, and orthopaedic surgery. Understanding these disparities will facilitate development of solutions aimed at eliminating disparities at the patient, physician/provider, and healthcare system levels.

Appendicitis Hospitalization Care Costs Among Patients With Delayed Diagnosis of Appendicitis

Importance

Delayed appendicitis diagnosis is associated with worse outcomes. Appendicitis hospital care costs associated with delayed diagnosis are unknown.

Objective

To determine whether delayed appendicitis diagnosis was associated with increased appendicitis hospital care costs.

Design, Setting, and Participants

This cohort study used data from patients receiving an appendectomy aged 18 to 64 years in 5 states (Florida, Maryland, Massachusetts, New York, Wisconsin) that were captured in the Healthcare Cost and Utilization Project State Inpatient and Emergency Department databases for the years 2016 and 2017 with no additional follow-up. Data were analyzed January through April 2023.

Exposures

Delayed diagnosis was defined as a previous emergency department or inpatient hospital encounter with an abdominal diagnosis other than appendicitis, and no intervention 7 days prior to appendectomy encounter.

Main Outcomes and Measures

The main outcome was appendicitis hospital care costs. This was calculated from aggregated charges of encounters 7 days prior to appendectomy, the appendectomy encounter, and 30 days postoperatively. Cost-to-charge ratios were applied to charges to obtain costs, which were then adjusted for wage index, inflation to 2022 US dollar, and with extreme outliers winsorized. A multivariable Poisson regression estimated appendicitis hospital care costs associated with a delayed diagnosis while controlling for age, sex, race and ethnicity, insurance status, care discontinuity, income quartile, hospital size, teaching status, medical school affiliation, percentage of Black and Hispanic patient discharges, core-based statistical area, and state.

Results

There were 76 183 patients (38 939 female [51.1%]; 2192 Asian or Pacific Islander [2.9%], 14 132 Hispanic [18.5%], 8195 non-Hispanic Black [10.8%], 46 949 non-Hispanic White [61.6%]) underwent appendectomy, and 2045 (2.7%) had a delayed diagnosis. Delayed diagnosis patients had median (IQR) unadjusted cost of $11 099 ($6752-$17 740) compared with $9177 ($5575-$14 481) for nondelayed (P < .001). Patients with delayed diagnosis had 1.23 times (95% CI, 1.16-1.28 times) adjusted increased appendicitis hospital care costs. The mean marginal cost of delayed diagnosis was $2712 (95% CI, $2083-$3342). Even controlling for delayed diagnosis, non-Hispanic Black patients had 1.22 times (95% CI, 1.17-1.28 times) the adjusted increased appendicitis hospital care costs compared with non-Hispanic White patients.

Conclusions and Relevance

In this cohort study, delayed diagnosis of appendicitis was associated with increased hospital care costs.

Racial and ethnic disparities in emergency department transfers to public hospitals

OBJECTIVE

To examine racial/ethnic differences in emergency department (ED) transfers to public hospitals and factors explaining these differences.

DATA SOURCES AND STUDY SETTING

ED and inpatient data from the Healthcare Cost and Utilization Project for Florida (2010-2019); American Hospital Association Annual Survey (2009-2018).

STUDY DESIGN

Logistic regression examined race/ethnicity and payer on the likelihood of transfer to a public hospital among transferred ED patients. The base model was controlled for patient and hospital characteristics and year fixed effects. Models II and III added urbanicity and hospital referral region (HRR), respectively. Model IV used hospital fixed effects, which compares patients within the same hospital. Models V and VI stratified Model IV by payer and condition, respectively. Conditions were classified as emergency care sensitive conditions (ECSCs), where transfer is protocolized, and non-ECSCs. We reported marginal effects at the means.

DATA COLLECTION/EXTRACTION METHODS

We examined 1,265,588 adult ED patients transferred from 187 hospitals.

PRINCIPAL FINDINGS

Black patients were more likely to be transferred to public hospitals compared with White patients in all models except ECSC patients within the same initial hospital (except trauma). Black patients were 0.5-1.3 percentage points (pp) more likely to be transferred to public hospitals than White patients in the same hospital with the same payer. In the base model, Hispanic patients were more likely to be transferred to public hospitals compared with White patients, but this difference reversed after controlling for HRR. Hispanic patients were - 0.6 pp to -1.2 pp less likely to be transferred to public hospitals than White patients in the same hospital with the same payer.

CONCLUSIONS

Large population-level differences in whether ED patients of different races/ethnicities were transferred to public hospitals were largely explained by hospital market and the initial hospital, suggesting that they may play a larger role in explaining differences in transfer to public hospitals, compared with other external factors.

Racial and Ethnic Disparities in Perioperative Health Care Among Patients Undergoing Cardiac Surgery: JACC State-of-the-Art Review

There has been little progress in reducing health care disparities since the 2003 landmark Institute of Medicine's report Unequal Treatment. Despite the higher burden of cardiovascular disease in underrepresented racial and ethnic groups, they have less access to cardiologists and cardiothoracic surgeons, and have higher rates of morbidity and mortality with cardiac surgical interventions. This review summarizes existing literature and highlights disparities in cardiovascular perioperative health care. We propose actionable solutions utilizing multidisciplinary perspectives from cardiology, cardiac surgery, cardiothoracic anesthesiology, critical care, medical ethics, and health disparity experts. Applying a health equity lens to multipronged interventions is necessary to eliminate the disparities in perioperative health care among patients undergoing cardiac surgery.

Surgical Cancer Care in Safety-Net Hospitals: a Systematic Review

BACKGROUND

Tertiary medical centers in the USA provide specialized, high-volume surgical cancer care, contributing standards for quality and outcomes. For the most vulnerable populations, safety-net hospitals (SNHs) remain the predominant provider of both complex and routine healthcare needs. The objective of this study was to evaluate access to and quality of surgical oncology care within SNHs.

METHODS

A comprehensive and systematic review of the literature was conducted using PubMed, EMBASE, and Cochrane Library databases to identify all studies (January 2000-October 2021) reporting the delivery of surgical cancer care at SNHs in the USA (PROSPERO #CRD42021290092). These studies describe the process and/or outcomes of surgical care for gastrointestinal, hepatopancreatobiliary, or breast cancer patients seeking treatment at SNHs.

RESULTS

Of 3753 records, 37 studies met the inclusion criteria. Surgical care for breast cancer (43%) was the most represented, followed by colorectal (30%) and hepatopancreatobiliary (16%) cancers. Financial constraints, cultural and language barriers, and limitations to insurance coverage were cited as common reasons for disparities in care within SNHs. Advanced disease at presentation was common among cancer patients seeking care at SNHs (range, 24-61% of patients). Though reports comparing cancer survival between SNHs and non-SNHs were few, results were mixed, underscoring the variability in care seen across SNHs.

CONCLUSIONS

These findings highlight barriers in care facing many cancer patients. Continued efforts should address improving both access and quality of care for SNH patients. Future models include a transition away from a two-tiered system of resourced and under-resourced hospitals toward an integrated cancer system.

Post-Operative Care of the Cancer Patient: Emphasis on Functional Recovery, Rapid Rescue, and Survivorship

A cancer diagnosis and its subsequent treatments are life-changing events, impacting the patient and their family. Treatment options available for cancer care are developing at pace, with more patients now able to achieve a cancer cure. This is achieved through the development of novel cancer treatments, surgery, and modern imaging, but also as a result of better understanding treatment/surgical trauma, rescue after complications, perioperative care, and innovative interventions like pre-habilitation, enhanced recovery, and enhanced post-operative care. With more patients living with and beyond cancer, the role of survivorship and quality of life after cancer treatment is gaining importance. The impact cancer treatments can have on patients vary, and the "scars" treatments leave are not always visible. To adequately support patients through their cancer journeys, we need to look past the short-term interactions they have with medical professionals and encourage them to consider their lives after cancer, which often is not a reflection of life before a cancer diagnosis.

Identifying the origin of socioeconomic disparities in outcomes of major elective operations

Background

While the impact of socioeconomic status (SES) on surgical outcomes has been examined in limited series, it remains a significant determinant of healthcare outcomes at the national level. Therefore, the current study aims to determine SES disparities at three time-points: hospital accessibility, in-hospital outcomes, and post-discharge consequences.

Methods

The Nationwide Readmissions Database 2010-2018 was used to isolate major elective operations. SES was assigned using previously coded median income quartiles as defined by patient zip-code, with low SES defined as the lowest quartile and high SES as the highest.

Results

Of an estimated 4,816,837 patients undergoing major elective operations, 1,037,689 (21.3 %) were categorized as low SES and 1,288,618 (26.5 %) as high. On univariate analysis and compared to those of low SES, high SES patients were more frequently treated at high-volume centers (70.9 vs 55.6 %, p < 0.001), had lower rates of in-hospital complications (24.0 vs 29.0 %, p < 0.001) and mortality (0.4 vs 0.9 %, p < 0.001) as well as less frequent urgent readmissions at 30- (5.7 vs 7.1 %, p < 0.001) and 90-day timepoints (9.4 vs 10.7 %, p < 0.001). On multivariable analysis, high SES patients had higher odds of treatment at high-volume centers (Odds: 1.87, 95 % CI: 1.71-2.06), and lower odds of perioperative complications (Odds: 0.98, 95 % CI: 0.96-0.99), mortality (Odds: 0.70, 95 % CI: 0.65-0.75), and urgent readmissions at 90-days (Odds: 0.95, 95 % CI: 0.92-0.98).

Conclusion

This study fills a much-needed gap in the current literature by establishing that all of the aforementioned timepoints include significant disadvantages for those of low socioeconomic status. Therefore, a multidisciplinary approach may be required for intervention to improve equity for surgical patients.

Acute clinical and financial outcomes of esophagectomy at safety-net hospitals in the United States

BACKGROUND

While safety-net hospitals (SNH) play a critical role in the care of underserved communities, they have been associated with inferior postoperative outcomes. This study evaluated the association of hospital safety-net status with clinical and financial outcomes following esophagectomy.

METHODS

All adults (≥18 years) undergoing elective esophagectomy for benign and malignant gastroesophageal disease were identified in the 2010-2019 Nationwide Readmissions Database. Centers in the highest quartile for the proportion of uninsured/Medicaid patients were classified as SNH (others: non-SNH). Regression models were developed to evaluate adjusted associations between SNH status and outcomes, including in-hospital mortality, perioperative complications, and resource use. Royston-Parmar flexible parametric models were used to assess time-varying hazard of non-elective readmission over 90 days.

RESULTS

Of an estimated 51,649 esophagectomy hospitalizations, 9,024 (17.4%) were performed at SNH. While SNH patients less frequently suffered from gastroesophageal malignancies (73.2 vs 79.6%, p<0.001) compared to non-SNH, the distribution of age and comorbidities were similar. SNH was independently associated with mortality (AOR 1.24, 95% CI 1.03-1.50), intraoperative complications (AOR 1.45, 95% CI 1.20-1.74) and need for blood transfusions (AOR 1.61, 95% CI 1.35-1.93). Management at SNH was also associated with incremental increases in LOS (+1.37, 95% CI 0.64-2.10), costs (+10,400, 95% CI 6,900-14,000), and odds of 90-day non-elective readmission (AOR 1.11, 95% CI 1.00-1.23).

CONCLUSIONS

Care at safety-net hospitals was associated with higher odds of in-hospital mortality, perioperative complications, and non-elective rehospitalization following elective esophagectomy. Efforts to provide sufficient resources at SNH may serve to reduce complications and overall costs for this procedure.

The relationship between safety-net hospital status and outcomes among elderly head and neck cancer patients

BACKGROUND

The impact of safety-net status, case volume, and outcomes among geriatric head and neck cancer patients is unknown.

METHODS

Chi-square tests and Student's t tests to compare head and neck surgery outcomes of elderly patients between safety-net and non-safety-net hospitals. Multivariable linear regressions to determine predictors of outcome variables including mortality index, ICU stays, 30-day readmission, total direct cost, and direct cost index.

RESULTS

Compared with non-safety-net hospitals, safety-net hospitals had a higher average mortality index (1.04 vs. 0.32, p = 0.001), higher mortality rate (1% vs. 0.5%, p = 0.002), and higher direct cost index (p = 0.001). A multivariable model of mortality index found the interaction between safety-net status and medium case volume was predictive of higher mortality index (p = 0.006).

CONCLUSION

Safety-net status is correlated with higher mortality index and cost in geriatric head and neck cancer patients. The interaction between medium volume and safety-net status is independently predictive of higher mortality index.

Clinical and financial outcomes of pulmonary resection for lung cancer in safety-net hospitals

OBJECTIVE

Safety-net hospitals (SNHs) have previously been associated with inferior outcomes and greater resource use. However, this relationship has not been explored in the contemporary setting of pulmonary lobectomy. In the present national study we characterized the association between SNHs and mortality, complications, and resource use.

METHODS

All adults (18 years of age or older) who underwent elective lobectomy for lung cancer were identified within the 2010 to 2019 Nationwide Readmissions Database. Hospitals in the highest quartile of safety-net burden were categorized as SNHs, and others non-SNHs. Multivariable regressions were developed to assess the independent association between safety-net status and outcomes of interest.

RESULTS

Of an estimated 282,011 patients who met inclusion criteria, 41,015 (14.5%) were treated at SNHs. Patients at SNHs were younger but as commonly female, compared with non-SNHs. After multivariable adjustment, there was no association between SNHs and mortality. However, treatment at SNHs was linked to higher odds of pneumonia (adjusted odds ratio [AOR], 1.11; 95% CI, 1.02-1.21) and prolonged ventilation (AOR, 1.36; 95% CI, 1.11-1.66), as well as infectious (AOR, 1.24; 95% CI, 1.08-1.43), intraoperative (AOR, 1.22; 95% CI, 1.07-1.39), and overall complications (AOR, 1.07; 95% CI, 1.01-1.14). Patients at SNHs also showed a greater need for a blood transfusion (AOR, 1.37; 95% CI, 1.23-1.53). In addition, SNHs were associated with increased length of stay (+0.33 days; 95% CI, 0.17-0.48) and greater costs (+$4130; 95% CI, 3.34-4.92), relative to non-SNHs.

CONCLUSIONS

Hospital safety-net status was associated with greater odds of perioperative complications and greater health care expenditure. Further investigation is necessary uncover the mechanisms contributing to these complications and eradicate persistent disparities in lobectomy.

Patient and Hospital Characteristics Associated With Delayed Diagnosis of Appendicitis

Importance

Racial disparities in timely diagnosis and treatment of surgical conditions exist; however, it is poorly understood whether there are hospital structural measures or patient-level characteristics that modify this phenomenon.

Objective

To assess whether patient race and ethnicity are associated with delayed appendicitis diagnosis and postoperative 30-day hospital use and whether there are patient- or systems-level factors that modify this association.

Design, Setting, and Participants

This population-based, retrospective cohort study used data from the Healthcare Cost and Utilization Project's state inpatient and emergency department (ED) databases from 4 states (Florida, Maryland, New York, and Wisconsin) for patients aged 18 to 64 years who underwent appendectomy from January 7, 2016, to December 1, 2017. Data were analyzed from January 1, 2016, to December 31, 2017.

Exposure

Delayed diagnosis of appendicitis, defined as an initial ED presentation with an abdominal diagnosis other than appendicitis followed by re-presentation within a week for appendectomy.

Main Outcomes and Measures

A mixed-effects multivariable Poisson regression model was used to estimate the association of delayed diagnosis of appendicitis with race and ethnicity while controlling for patient and hospital variables. A second mixed-effects multivariable Poisson regression model quantified the association of delayed diagnosis of appendicitis with postoperative 30-day hospital use.

Results

Of 80 312 patients who received an appendectomy during the study period (median age, 38 years [IQR, 27-50 years]; 50.8% female), 2013 (2.5%) experienced delayed diagnosis. In the entire cohort, 2.9% of patients were Asian or Pacific Islander, 18.8% were Hispanic, 10.9% were non-Hispanic Black, 60.8% were non-Hispanic White, and 6.6% were other race and ethnicity; most were privately insured (60.2%). Non-Hispanic Black patients had a 1.41 (95% CI, 1.21-1.63) times higher adjusted rate of delayed diagnosis compared with non-Hispanic White patients. Patients at hospitals with a more than 50% Black or Hispanic population had a 0.73 (95% CI, 0.59-0.91) decreased adjusted rate of delayed appendicitis diagnosis compared with hospitals with a less than 25% Black or Hispanic population. Conversely, patients at hospitals with more than 50% of discharges of Medicaid patients had a 3.51 (95% CI, 1.69-7.28) higher adjusted rate of delayed diagnosis compared with hospitals with less than 10% of discharges of Medicaid patients. Additional factors associated with delayed diagnosis included female sex, higher levels of patient comorbidity, and living in a low-income zip code. Delayed diagnosis was associated with a 1.38 (95% CI, 1.36-1.61) increased adjusted rate of postoperative 30-day hospital use.

Conclusions and Relevance

In this cohort study, non-Hispanic Black patients had higher rates of delayed appendicitis diagnosis and 30-day hospital use than White patients. Patients presenting to hospitals with a greater than 50% Black and Hispanic population were less likely to experience delayed diagnosis, suggesting that seeking care at a hospital that serves a diverse patient population may help mitigate the increased rate of delayed diagnosis observed for non-Hispanic Black patients.

Patient safety indicators from a spine surgery perspective: the importance of a specialty specific clinician working with the documentation team and the impact to your hospital

BACKGROUND CONTEXT

The Hospital Acquired Conditions (HAC) Reduction Program supports the Centers for Medicare and Medicaid Services (CMS) effort to prevent harm to patients by providing a financial incentive to reduce HACs. HAC scores are impacted by Patient Safety Indicators (PSIs), potentially preventable hospital-related events associated with harmful patient outcomes. PSIs are identified using International Classification of Diseases (ICD) coding; however, ICD coding does not always reflect the patient's true medical course.

PURPOSE

To evaluate the efficacy of and costs savings associated with a clinical documentation review process in tandem with clinician collaboration in identifying incorrectly generated PSIs.

STUDY DESIGN

Retrospective chart review.

PATIENT SAMPLE

All patients undergoing spine surgery at a single multi-surgeon tertiary spine center.

OUTCOME MEASURES

Occurrence of PSI.

METHODS

Over two 11-month periods, all PSIs attributable to spine surgery were determined. The number and type of spine related PSIs were compared before (Control) and after the implementation of a specialty specific clinical review (Intervention) to identify incorrectly generated PSIs. The financial impact of this intervention was calculated in the form of an annual cost savings to our hospital system.

RESULTS

During the Control phase, 61 PSIs were reported in 3368 spine cases, representing a total of 3.6 PSIs/month. During Intervention phase, 26 PSIs in 4,482 spine cases, resulting in a statistically significant decrease of 1.5 PSIs per month. The percentage of PSIs across all surgical cases attributable to spine surgery had a statistically significant decrease during the Intervention period compared to the Control period (16% vs. 10%, p=.034), resulting in the avoidance of a 1% CMS cost reduction, an annual cost saving of approximately $3-4 million dollars per year.

CONCLUSIONS

The implementation of a clinical documentation review process with clinician collaboration to ensure ICD-10 coding accurately reflects the patient's medical course leads to more accurate PSI reporting, with the potential for substantial cost-savings for hospitals from CMS reimbursement.

Association between Patient and Hospital Characteristics and Adherence to a Surgical Site Infection Reduction Bundle in a Statewide Surgical Quality Improvement Collaborative

BACKGROUND

Adherence to bundled interventions can reduce surgical site infection (SSI) rates; however, predictors of successful implementation are poorly characterized. We studied the association of patient and hospital characteristics with adherence to a colorectal SSI reduction bundle across a statewide surgical collaborative.

STUDY DESIGN

A 16-component colorectal SSI reduction bundle was introduced in 2016 across a statewide quality improvement collaborative. Bundle adherence was measured for patients who underwent colorectal operations at participating institutions. Multivariable mixed-effects logistic regression models were constructed to estimate associations of patient and hospital factors with bundle adherence and quantify sources of variation.

RESULTS

Among 2,403 patients at 35 hospitals, a median of 11 of 16 (68.8%, interquartile range 8 to 13) bundle elements were completed. The likelihood of completing 11 or more elements was increased for obese patients (56.8% vs 51.5%, odds ratio [OR] 1.39, 95% CI 1.05 to 1.86, p = 0.022) but reduced for underweight patients (31.0% vs 51.5%, OR 0.51, 95% CI 0.26 to 1.00, p = 0.048) compared with patients with a normal BMI. Lower adherence was noted for patients treated at safety net hospitals (n = 9 hospitals, 24.4% vs 54.4%, OR 0.08, 95% CI 0.01 to 0.44, p = 0.004). The largest proportion of adherence variation was attributable to hospital factors for six bundle elements, surgeon factors for no elements, and patient factors for nine elements.

CONCLUSION

Adherence to an SSI reduction bundle is associated with patient BMI and hospital safety net status. Quality improvement groups should consider institutional traits for optimal implementation of SSI bundles. Safety net hospitals may require additional focus to overcome unique implementation barriers.

Evaluation of the Merit-Based Incentive Payment System and Surgeons Caring for Patients at High Social Risk

Importance

The latest step in the Centers for Medicaid & Medicare transformation to pay-for-value is the Medicare Merit-Based Incentive Payment System (MIPS). Value-based payment designs often do not account for uncaptured clinical status and social determinants of health in patients at high social risk, and the consequences for clinicians and patients associated with their use have not been explored.

Objective

To evaluate MIPS scoring of surgeons caring for patients at high social risk to determine whether this implementation threatens disadvantaged patients' access to surgical care.

Design, Setting, and Participants

A retrospective cohort study of US general surgeons participating in MIPS during its first year in outpatient surgical practices across the US and territories. The study was conducted from September 1, 2020, to May 1, 2021. Data were analyzed from November 1, 2020, to March 30, 2021 (although data were collected during the 2017 calendar year and reported ahead of 2019 payment adjustments).

Main Outcomes and Measures

Characteristics of surgeons participating in MIPS, overall MIPS score assigned to clinician. and practice-level disadvantage measures. The MIPS scores can range from 0 to 100. For the first year, a score of less than 3 led to negative payment adjustment; a score of greater than 3 but less than 70 to a positive adjustment; and a score of 70 or higher to the exceptional performance bonus.

Results

Of 20 593 general surgeons, 10 252 participated in the first year of MIPS. Surgeons with complete patient data (n = 9867) were evaluated and a wide range of dual-eligible patient caseloads from 0% to 96% (mean [SD], 27.1% [14.5%]) was identified. Surgeons in the highest quintile of dual eligibility cared for a Medicare patient caseload ranging from 37% to 96% dual eligible for Medicare and Medicaid. Surgeons caring for the patients at highest social risk had the lowest final mean (SD) MIPS score compared with the surgeons caring for the patients at least social risk (66.8 [37.3] vs 71.2 [35.9]; P < .001).

Conclusions and Relevance

Results of this cohort study suggest that implementation of MIPS value-based care reimbursement without adjustment for caseload of patients at high social risk may penalize surgeons who care for patients at highest social risk.

Hospital safety-net burden is associated with increased inpatient mortality after elective total knee arthroplasty: a retrospective multistate review, 2007-2018

BACKGROUND

Total knee arthroplasty (TKA) is among the most common surgical procedures performed in the USA and comprises an outsized proportion of Medicare expenditures. Previous work-associated higher safety-net burden hospitals with increased morbidity and in-hospital mortality following total hip arthroplasty. Here, we examine the association of safety-net burden on postoperative outcomes after TKA.

METHODS

We retrospectively analyzed 1 141 587 patients aged ≥18 years undergoing isolated elective TKA using data from the State Inpatient Databases for Florida, Kentucky, Maryland, New York and Washington from 2007 through 2018. Hospitals were grouped into tertiles by safety-net burden status, defined by the proportion of inpatient cases billed to Medicaid or unpaid (low: 0%-16.83%, medium: 16.84%-30.45%, high: ≥30.45%). Using generalized estimating equation models, we assessed the association of hospital safety-net burden status on in-hospital mortality, patient complications and length of stay (LOS). We also analyzed outcomes by anesthesia type in New York State (NYS), the only state with this data.

RESULTS

Most TKA procedures were performed at medium safety-net burden hospitals (n=6 16 915, 54%), while high-burden hospitals performed the fewest (n=2 04 784, 17.9%). Overall in-patient mortality was low (0.056%), however, patients undergoing TKA at medium-burden hospitals were 40% more likely to die when compared with patients at low-burden hospitals (low: 0.043% vs medium: 0.061%, adjusted OR (aOR): 1.40, 95% CI 1.09 to 1.79, p=0.008). Patients who underwent TKA at medium or high safety-net burden hospitals were more likely to experience intraoperative complications (low: 0.2% vs medium: 0.3%, aOR: 1.94, 95% CI 1.34 to 2.83, p<0.001; low: 0.2% vs high: 0.4%, aOR: 1.91, 95% CI 1.35 to 2.72, p<0.001). There were no statistically significant differences in other postoperative complications or LOS between the different safety-net levels. In NYS, TKA performed at high safety-net burden hospitals was more likely to use general rather than regional anesthesia (low: 26.7% vs high: 59.5%, aOR: 4.04, 95% CI 1.05 to 15.5, p=0.042).

CONCLUSIONS

Patients undergoing TKA at higher safety-net burden hospitals are associated with higher odds of in-patient mortality than those at low safety-net burden hospitals. The source of this mortality differential is unknown but could be related to the increased risk of intraoperative complications at higher burden centers.

Interprofessional Consultations (eConsults) in Urology

INTRODUCTION

An interprofessional consultation (eConsult) is an asynchronous form of telehealth whereby a primary care provider requests electronic consultation with a specialist in place of an in-person consultation. While eConsults have been successfully implemented in many medical specialties, their use in the practice of urology is relatively unknown.

METHODS

We included data from four academic institutions: University of Michigan, University of California -San Francisco, University of Washington, and Montefiore Medical Center. We included every urological eConsult performed at each institution from the launch of their respective programs through August 2019. We considered an eConsult "converted" when the participating urologist recommended a full in-person evaluation. We report eConsult conversion rate, response time, completion time, and diagnosis categories.

RESULTS

A total of 462 urological eConsults were requested. Of these, 36% were converted to a traditional in-person visit. Among resolved eConsults, with data on provider response time available (n=119),53.8% of eConsults were addressed in less than 1 day; 28.6% in 1 day; 8.4% in 2 days; 3.4% in 3 days; 3.4% in 4 days; 1.7% in 5 days; and 0.8% in ≥6 days. Among resolved eConsults, with data on provider completion time available (n=283), 50.2% were completed in 1-10 minutes; 46.7% in 11-20 minutes; 2.8% in 21-30 minutes; and less than 1% in ≥31 minutes.

DISCUSSION

Our study suggests that eConsults are an effective avenue for urologists to provide recommendations for many common non-surgical urological conditions and thus avoid a traditional in-person for low-complexity situations. Further investigation into the impact of eConsults on healthcare costs and access to urological care are necessary.

Patient race and racial composition of delivery unit associated with disparities in severe maternal morbidity: a multistate analysis 2007-2014

BACKGROUND

High Black-serving delivery units and high hospital safety-net burden have been associated with poorer patient outcomes. We examine these hospital-level factors and their association with severe maternal morbidity (SMM), independently and as effect modifiers of patient-level factors.

METHODS

Using the 2007-2014 State Inpatient Databases (Florida, New York, California, Maryland, Kentucky), we analyzed delivery hospitalizations. We constructed generalized linear mixed models with patient- and hospital-level variables (Black-serving delivery units: high: top 5th percentile; medium: 5th-25th percentile; low: bottom 75th percentile; hospital safety-net burden status defined by insurance status) and report adjusted odds ratios (aOR) and 99% confidence intervals (CI). We repeated our mixed models with stratification and interaction analysis.

RESULTS

6 879 332 delivery hospitalizations were included in the analysis. Deliveries at high (aOR 1.83; 99% CI 1.34 to2.50) or medium (aOR 1.27; 99% CI 1.10 to 1.46) Black-serving delivery units were more likely to have SMM than deliveries at low Black-serving delivery units. Hospital safety-net burden was not significantly associated with SMM. In stratified models by hospital category, deliveries of Black women were associated with an increase in SMM compared with deliveries of White women in all hospital categories. In interaction models, Black women giving birth in high Black-serving delivery units had more than twice the odds of White women in low Black-serving delivery units of experiencing SMM (aOR 2.42; 99% CI 1.90 to 3.08).

CONCLUSION

The patient racial/ethnic composition of the delivery unit is associated with adjusted-odds of SMM, both independently and interactively with individual patient race.

Optimizing Surgeon Well-Being: A Review and Synthesis of Best Practices

Through a systematic review and mixed-methods meta-synthesis of the existing literature on surgeon well-being, we sought to identify the specific elements of surgeon well-being, examine factors associated with suboptimal well-being, and highlight opportunities to promote well-being.

Background

Suboptimal surgeon well-being has lasting and substantial impacts to the individual surgeon, patients, and to society as a whole. However, most of the existing literature focuses on only 1 aspect of well-being-burnout. While undoubtedly a crucial component of overall well-being, the mere absence of burnout does not fully consider the complexities of being a surgeon.

Methods

We performed a literature search within Ovid Medline, Elsevier Excerpta Medica dataBASE, EBSCOhost Cumulative Index to Nursing and Allied Health Literature, and Clarivate Web of Science from inception to May 7, 2020, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies with primary data examining surgeon well-being were included. Using a predetermined instrument, data were abstracted from each study and compared using thematic analysis.

Results

A total of 5369 abstracts were identified and screened, with 184 full articles (172 quantitative, 3 qualitative, 9 mixed methods) selected for analysis. Among these, 91 articles measured burnout, 82 examined career satisfaction, 95 examined work-related stressors, 44 explored relationships and families, and 85 assessed emotional and physical health. Thematic analysis revealed 4 themes: professional components, personal components, work-life balance, and impacts to well-being.

Conclusions

Surgeon well-being is complex and multifaceted. This nuanced examination of surgeon well-being highlights the critical need to develop and provide more long-term support to surgeons-with interventions being tailored based on individual, institutional, and systemic factors.

Outcomes and Resource Use Associated With Acute Respiratory Failure in Safety Net Hospitals Across the United States

BACKGROUND

Despite the frequency and cost of hospitalizations for acute respiratory failure (ARF), the literature regarding the impact of hospital safety net burden on outcomes of these hospitalizations is sparse.

RESEARCH QUESTION

How does safety net burden impact outcomes of ARF hospitalizations such as mortality, tracheostomy, and resource use?

STUDY DESIGN AND METHODS

This was a retrospective cohort study using the National Inpatient Sample 2007-2017. All patients hospitalized with a primary diagnosis of ARF were tabulated using the International Classification of Diseases 9th and 10th Revision codes, and safety net burden was calculated using previously published methodology. High- and low-burden hospitals were generated from proportions of Medicaid and uninsured patients. Trends were analyzed using a nonparametric rank-based test, whereas multivariate logistic and linear regression models were used to establish associations of safety net burden with key clinical outcomes.

RESULTS

Of an estimated 8,941,334 hospitalizations with a primary diagnosis of ARF, 33.9% were categorized as occurring at low-burden hospitals (LBHs) and 31.6% were categorized as occurring at high-burden hospitals (HBHs). In-hospital mortality significantly decreased at HBHs (22.8%-12.6%; nonparametric trend [nptrend] < .001) and LBHs (22.0%-10.9%; nptrend < .001) over the study period, as did tracheostomy placement (HBH, 5.6%-1.3%; LBH, 3.5%-0.8%; all nptrend <.001). After adjustment for patient and hospital factors, an HBH was associated with increased odds of mortality (adjusted OR [AOR], 1.11; 95% CI, 1.10-1.12) and tracheostomy use (AOR, 1.33; 95% CI, 1.29-1.37), as well as greater hospitalization costs (β coefficient, +$1,083; 95% CI, $882-$1,294) and longer lengths of stay (β coefficient, +3.3 days; 95% CI, 3.2-3.3 days).

INTERPRETATION

After accounting for differences between patient cohorts, high safety net burden was associated independently with inferior clinical outcomes and increased costs after ARF hospitalizations. These findings emphasize the need for health care reform to ameliorate disparities within these safety net centers, which treat our most vulnerable populations.

Overcoming disparities: Multidisciplinary breast cancer care at a public safety net hospital

PURPOSE

Public safety net hospitals (SNH) serve a disparate patient population; however, little is known about long-term oncologic outcomes of patients receiving care at these facilities. This study is the first to examine overall survival (OS) and the initiation of treatment in breast cancer patients treated at a SNH.

METHODS

Patients presenting to a SNH with stage I-IV breast cancer from 2005 to 2017 were identified from the local tumor registry. The hospital has a weekly breast tumor board and a multidisciplinary approach to breast cancer care. Kaplan-Meier survival analysis was performed to identify patient, tumor, and treatment characteristics associated with OS. Factors with a p < 0.1 were included in the Cox proportional hazards model.

RESULTS

2709 breast cancer patients were evaluated from 2005 to 2017. The patient demographics, tumor characteristics, and treatments received were analyzed. Five-year OS was 78.4% (93.9%, 87.4%, 70.9%, and 23.5% for stages I, II, III, and IV, respectively). On multivariable analysis, higher stage, age > 70 years, higher grade, and non-Hispanic ethnicity were associated with worse OS. Patients receiving surgery (HR = 0.33, p < 0.0001), chemotherapy (HR = 0.71, p = 0.006), and endocrine therapy (HR = 0.61, p < 0.0001) had better OS compared to those who did not receive these treatments.

CONCLUSION

Despite serving a vulnerable minority population that is largely poor, uninsured, and presenting with more advanced disease, OS at our SNH approaches national averages. This novel finding indicates that in the setting of multidisciplinary cancer care and with appropriate initiation of treatment, SNHs can overcome socioeconomic barriers to achieve equitable outcomes in breast cancer care.

Timely Care is Patient-Centered Care for Patients with Acute Cholecystitis at a Safety-Net Hospital

BACKGROUND

Multiple strategies exist to improve the timeliness and efficiency of surgical care at safety-net hospitals (SNH), such as acute care surgery models and nighttime surgery. However, the patient-centeredness of such approaches is unknown.

METHODS

Adults ( ≥18 years) with acute cholecystitis were interviewed upon admission to a SNH. Interviews were semi-structured and designed to obtain both exploratory qualitative data and ratings of patient-centered outcomes, ranked by importance to the patient. Outcomes included for rating were general health, symptom status, quality of life, and return to prior functional status. Latent content analysis applying inductive coding methods were used to code and condense raw qualitative data from interview transcripts.

RESULTS

Thematic saturation was reached with a sample size of 15 patients. Most participants were female (87%), Hispanic (87%), and had prior diagnosis of benign biliary disease (60%). Patients identified symptom resolution as the highest-ranked outcome in their treatment. Themes expressed by patients during the exploratory segments of the interview included: desire for pain alleviation, frustration with delays to both symptom resolution and surgical intervention, lack of perceived control over their health care, and reticence in discussing preferences with physicians. All patients preferred to have surgical treatment as soon as possible, even if that meant having nighttime surgery.

CONCLUSIONS

Effective and timely resolution of symptoms is of utmost importance to patients with acute cholecystitis at a SNH. Efforts to improve timeliness of surgical care are also perceived as patient-centered.

Dissecting disease, race, ethnicity, and socioeconomic factors for hepatocellular carcinoma: An analysis from the United States Safety Net Collaborative

BACKGROUND

Racial/ethnic and socioeconomic disparities are assumed to negatively affect treatment and outcomes for hepatocellular carcinoma (HCC). Our aim was to investigate the interaction of racial/ethnic and socioeconomic factors with stage of disease and type of treatment facility in receipt of treatment and overall survival (OS) of patients with HCC.

METHODS

All patients with primary HCC in the US Safety-Net Collaborative database (2012-2014) were included. Patients were categorized into "safety-net" or "tertiary referral center" based on where they received treatment. Socioeconomic factors were determined at the zip-code level and included median income and percent of adults who graduated from high-school. Primary outcomes were receipt of treatment and OS.

RESULTS

On MV Cox regression, neither race/ethnicity, median income, nor care provided at a SNH were associated with decreased OS (all p > 0.05). Independent predictors of decreased OS included lack of insurance (HR 1.34), less educational attainment (HR 1.59) higher MELD score (HR 1.07), higher stage at diagnosis (II:HR 1.34, III:HR 2.87, IV:HR 3.23), and not receiving treatment (HR 3.94) (all p < 0.05). Factors associated with not receiving treatment included history of alcohol abuse (OR 0.682), increasing MELD (OR 0.874), higher stage at diagnosis (III: OR 0.234, IV: OR 0.210) and care at a safety net facility (OR 0.424) There were no racial/ethnic or socioeconomic disparities in receipt of treatment.

CONCLUSIONS

There is no intrinsic or direct association of race/ethnicity, socioeconomic status, or being treated at select safety-net hospitals with worse outcomes. Poor liver function, no insurance, and advanced stage of presentation are the main determinants of not receiving treatment and decreased survival.

Treatment of Acute Cholecystitis at Safety-Net Hospitals: Analysis of the National Inpatient Sample

Evidence supports index cholecystectomy as the quality of care for patients admitted with acute cholecystitis. We sought to examine the role of hospital safety-net status on whether patients received appropriate index procedures for cholecystitis. The National Inpatient Sample was queried for patients with acute cholecystitis. Proportion of Medicaid and uninsured discharges were used to define safety-net hospitals (SNHs). Multivariate logistic regression was used to calculate associations between the frequency of index cholecystectomy and prolonged length of stay (LOS), and the effect of SNH designation. SNHs and non-SNHs had similar rates of index cholecystectomy in all geographic regions, except in the northeast, where the likelihood of having an index cholecystectomy was lower at SNHs. Patients at SNHs had longer LOS for acute cholecystitis, regardless of index or delayed cholecystectomy. When controlling for insurance status, patients at SNHs had longer LOS than those at non-SNHs. There was also increased LOS in SNHs in the Midwest, in urban hospitals, and in large hospitals. Our data showed no difference in the frequency of index cholecystectomy overall between SNHs and non-SNHs, except in the northeast. The variability and increased LOS at SNHs highlight potential opportunities to improve quality and decrease cost of care at our most vulnerable hospitals.

Failure to rescue after major abdominal surgery: The role of hospital safety net burden

BACKGROUND

We aimed to examine whether safety-net burden is a significant predictor of failure-to-rescue (FTR) after major abdominal surgery controlling for patient and hospital characteristics, including surgical volume.

METHODS

Data were extracted from the 2007-2011 Nationwide Inpatient Sample. FTR was defined as mortality among patients experiencing major postoperative complications. Differences in rates of complications, mortality, and FTR across quartiles of safety-net burden were assessed with univariate analyses. Multilevel regression models were constructed to estimate the association between FTR and safety-net burden.

RESULTS

Among 238,645 patients, the incidence of perioperative complications, in-hospital mortality, and FTR were 33.7%, 4.4%, and 11.8%, respectively. All the outcomes significantly increased across the quartiles of safety-net burden. In the multilevel regression analyses, safety-net burden was a significant predictor of FTR after adjustment for patient and hospital characteristics, including hospital volume.

CONCLUSION

Increasing hospital safety-net burden is associated with higher odds of FTR for major abdominal surgery.

The effect of hospital safety-net burden on outcomes, cost, and reportable quality metrics after emergent clipping and coiling of ruptured cerebral aneurysms

OBJECTIVE

Safety-net hospitals deliver care to a substantial share of vulnerable patient populations and are disproportionately impacted by hospital payment reform policies. Complex elective procedures performed at safety-net facilities are associated with worse outcomes and higher costs. The effects of hospital safety-net burden on highly specialized, emergent, and resource-intensive conditions are poorly understood. The authors examined the effects of hospital safety-net burden on outcomes and costs after emergent neurosurgical intervention for ruptured cerebral aneurysms.

METHODS

The authors conducted a retrospective analysis of the Nationwide Inpatient Sample (NIS) from 2002 to 2011. Patients ≥ 18 years old who underwent emergent surgical clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage (SAH) were included. Safety-net burden was defined as the proportion of Medicaid and uninsured patients treated at each hospital included in the NIS database. Hospitals that performed clipping and coiling were stratified as low-burden (LBH), medium-burden (MBH), and high-burden (HBH) hospitals.

RESULTS

A total of 34,647 patients with ruptured cerebral aneurysms underwent clipping and 23,687 underwent coiling. Compared to LBHs, HBHs were more likely to treat black, Hispanic, Medicaid, and uninsured patients (p < 0.001). HBHs were also more likely to be associated with teaching hospitals (p < 0.001). No significant differences were observed among the burden groups in the severity of subarachnoid hemorrhage. After adjusting for patient demographics and hospital characteristics, treatment at an HBH did not predict in-hospital mortality, poor outcome, length of stay, costs, or likelihood of a hospital-acquired condition.

CONCLUSIONS

Despite their financial burden, safety-net hospitals provide equitable care after surgical clipping and endovascular coiling for ruptured cerebral aneurysms and do not incur higher hospital costs. Safety-net hospitals may have the capacity to provide equitable surgical care for highly specialized emergent neurosurgical conditions.

Disparities in length of stay for hip fracture treatment between patients treated in safety-net and non-safety-net hospitals

Background

Length of hospital stay (LOS) for hip fracture treatments is associated with mortality. In addition to patient demographic and clinical factors, hospital and payer type may also influence LOS, and thus mortality, among hip fracture patients; accordingly, outcome disparities between groups may arise from where patients are treated and from their health insurance type. The purpose of this study was to examine if where hip fracture patients are treated and how they pay for their care is associated with outcome disparities between patient groups. Specifically, we examined whether LOS differed between patients treated at safety-net and non-safety-net hospitals and whether LOS was associated with patients’ insurance type within each hospital category.

Methods

A sample of 48,948 hip fracture patients was extracted from New York State’s Statewide Planning and Research Cooperative System (SPARCS), 2014–2016. Using means comparison and X² tests, differences between safety-net and non-safety-net hospitals on LOS and patient characteristics were examined. Relationships between LOS and hospital category (safety-net or non-safety-net) and LOS and insurance type were further evaluated through negative binomial regression models.

Results

LOS was statistically (p ≤ 0.001) longer in safety-net hospitals (7.37 days) relative to non-safety-net hospitals (6.34 days). Treatment in a safety-net hospital was associated with a LOS that was 11.7% (p = 0.003) longer than in a non-safety-net hospital. Having Medicaid was associated with a longer LOS relative to having commercial health insurance.

Conclusion

Where hip fracture patients are treated is associated with LOS and may influence outcome disparities between groups. Future research should examine whether outcome differences between safety-net and non-safety-net hospitals are associated with resource availability and hospital payer mix.

Correlation between hospital finances and quality and safety of patient care

Background

Hospitals under financial pressure may struggle to maintain quality and patient safety and have worse patient outcomes relative to well-resourced hospitals. Poor predictive validity may explain why previous studies on the association between finances and quality/safety have been equivocal. This manuscript employs principal component analysis to produce robust measures of both financial status and quality/safety of care, to assess our a priori hypothesis: hospital financial performance is associated with the provision of quality care, as measured by quality and safety processes, patient outcomes, and patient centered care.

Methods

This 2014 cross-sectional study investigated hospital financial condition and hospital quality and safety at acute care hospitals. The hospital financial data from the Centers for Medicare and Medicaid Services (CMS) cost report were used to develop a composite financial performance score using principal component analysis. Hospital quality and patient safety were measured with a composite quality/safety performance score derived from principal component analysis, utilizing a range of established quality and safety indicators including: risk-standardized inpatient mortality, 30-day mortality, 30-day readmissions for select conditions, patient safety indicators from inpatient admissions, process of care chart reviews, CMS value-based purchasing total performance score and patient experience of care surveys. The correlation between the composite financial performance score and the composite quality/safety performance score was calculated using linear regression adjusting for hospital characteristics.

Results

Among the 108 New York State acute care facilities for which data were available, there is a clear relationship between hospital financial performance and hospital quality/safety performance score (standardized correlation coefficient 0.34, p<0.001). The composite financial performance score is also positively associated with the CMS Value Based Purchasing Total Performance Score (standardized correlation coefficient 0.277, p = 0.002); while it is negatively associated with 30 day readmission for all outcomes (standardized correlation coefficient -0.236, p = 0.013), 30-day readmission for congestive heart failure (standardized correlation coefficient -0.23, p = 0.018), 30 day readmission for pneumonia (standardized correlation coefficient -0.209, p = 0.033), and a decrease in 30-day mortality for acute myocardial infarction (standardized correlation coefficient -0.211, p = 0.027). Used alone, operating margin and total margin are poor predictors of quality and safety outcomes.

Conclusions

Strong financial performance is associated with improved patient reported experience of care, the strongest component distinguishing quality and safety. These findings suggest that financially stable hospitals are better able to maintain highly reliable systems and provide ongoing resources for quality improvement.

Enhanced Recovery Pathway Improves Colorectal Surgery Outcomes in Private and Safety-Net Settings

BACKGROUND

Enhanced recovery pathways (ERPs) can decrease length of stay (LOS) and improve colorectal surgery outcomes in private health care; however, their efficacy in the public realm, comprised largely of underserved and uninsured patients, remains uncertain.

MATERIALS AND METHODS

An ERP without social interventions was implemented at a private hospital (PH) and a safety-net hospital (SNH) within a large academic medical center in 2014. Process and outcome metrics from 100 patients in the 18 mo before ERP implementation at each institution were retrospectively compared with a similar group after ERP implementation. Primary outcomes were LOS, 30-d readmission, and reoperation.

RESULTS

Post-ERP groups were older than pre-ERP (P = 0.047, 0.034), with no difference in sex or body mass index. Rate of open versus minimally invasive was similar at the SNH (P = 0.067), whereas more post-ERP patients at PH underwent open surgery (P = 0.002). Ninety six percentage of PH patients were funded through private insurance or Medicare, verses 6% at the SNH. LOS at PH decreased from 8.1 to 5.9 d (P = 0.028) and at SNH from 7.0 to 5.1 d (P = 0.004). There was no change in 30-d all-cause readmission (PH P = 0.634; SNH P = 1) or reoperation (PH P = 0.610; SNH P = 0.066).

CONCLUSIONS

ERP reduced LOS in both private and safety-net settings without addressing social determinants of health. Readmission and reoperation rates were unchanged. As health care moves toward a bundled payment model, ERP can help optimize outcomes and control costs in the public arena.

Impact of hospital safety-net status on failure to rescue after major cardiac surgery

BACKGROUND

Hospitals with safety-net status have been associated with inferior surgical outcomes and higher costs. The mechanism of this discrepancy, however, is not well understood. We hypothesized that discrepant rates of failure to rescue after complications of routine cardiac surgery would explain the observed inferior outcomes at safety-net hospitals.

METHODS

The National Inpatient Sample was used to identify adult patients who underwent elective coronary artery bypass grafting and isolated or concomitant valve operations between January 2005 and December 2016. Hospitals were stratified into low-, medium-, or high-burden categories based on the proportion of uninsured or Medicaid patients to emulate safety-net status as defined by the Institute of Medicine. Failure to rescue was defined as mortality after occurrence of neurologic, cardiovascular, respiratory, renal, or infectious complications (major and minor complications). Multivariable regression was used to perform risk-adjusted comparisons of the rate of complications, failures to rescue, and resource use for high-burden hospitals versus low-burden and medium-burden hospitals.

RESULTS

Of an estimated 2,012,104 patients undergoing elective major cardiac operations, 2% died, whereas 36% suffered major and minor complications. Safety-net hospitals had higher odds of failure to rescue after major comorbidity (adjusted odds ratio 1.12, 95% confidence interval 1.01-1.23). Occurrence of major and minor complications at safety-net hospitals was associated with increased costs ($2,480 [95% confidence interval $1,178-$3,935]) compared with low-burden hospitals.

CONCLUSION

Safety-net hospitals were associated with higher rates of failure to rescue after occurrence of tamponade, septicemia, and respiratory complications. Implementation of care bundles to tackle cardiovascular, respiratory, and renal complications may affect the discrepancy in incidence of and rescue from complications at safety-net institutions.

Hospital safety net burden is associated with increased inpatient mortality and postoperative morbidity after total hip arthroplasty: a retrospective multistate review, 2007-2014

BACKGROUND

Total hip arthroplasty (THA) is one of the most widely performed surgical procedures in the USA. Safety net hospitals, defined as hospitals with a high proportion of cases billed to Medicaid or without insurance, deliver a significant portion of their care to vulnerable populations, but little is known about the effects of a hospital's safety net burden and its role in healthcare disparities and outcomes following THA. We quantified safety net burden and examined its impact on in-hospital mortality, complications and length of stay (LOS) in patients who underwent THA.

METHODS

We analyzed 500 189 patient discharge records for inpatient primary THA using data from the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland and Kentucky from 2007 to 2014. We compared patient demographics, present-on-admission comorbidities and hospital characteristics by hospital safety net burden status. We estimated mixed-effect generalized linear models to assess hospital safety burden status' effect on in-hospital mortality, patient complications and LOS.

RESULTS

Patients undergoing THA at a hospital with a high or medium safety net burden were 38% and 30% more likely, respectively, to die in-hospital compared with those in a low safety net burden hospital (high adjusted OR: 1.38, 95% CI 1.10 to 1.73; medium adjusted OR: 1.30, 95% CI 1.07 to 1.57). Compared with patients treated in hospitals with a low safety net burden, patients treated in high safety net hospitals were more likely to develop a postoperative complication (adjusted OR: 1.11, 95% CI 1.00 to 1.24) and require a longer LOS (adjusted IRR: 1.06, 95% CI 1.05, 1.07).

CONCLUSIONS

Our study supports our hypothesis that patients who underwent THA at hospitals with higher safety net burden have poorer outcomes than patients at hospitals with lower safety net burden.

Quality of Care and Outcomes of Patients With Gynecologic Malignancies Treated at Safety-Net Hospitals

Background

Although safety-net hospitals (SNH) provide a valuable role serving vulnerable patients, the quality of gynecologic oncology care at these hospitals remains inadequately documented. We examined the quality of care at SNH for women with gynecologic cancers.

Methods

We used the National Cancer Database to identify hospitals that treated patients with uterine, ovarian, or cervical cancer from 2004 to 2015. Hospitals with the greatest proportion of uninsured patients or Medicaid beneficiaries were defined as SNH. Quality metrics were derived from evidence-based recommendations. Thirty-day mortality, readmission rates, and 5-year survival were calculated. Multivariable models were developed to determine the association between treatment at SNH and outcomes.

Results

Overall, 594 750 patients diagnosed with gynecologic cancer were treated at 1340 hospitals. Compared with non-SNH, patients at SNH were younger, more frequently racial minorities, low income, and had more aggressive histologies and advanced-stage tumors. SNH had lower rates of minimally invasive surgery for uterine cancer (62.3% vs 75.9%, P < .0001), debulking for ovarian cancer (83.6% vs 86.9%, P < .05), and lymph node assessment for all three cancer types (P < .05). Rates of chemotherapy for uterine and ovarian cancer was greater whereas concurrent chemoradiation for cervical cancer was lower (P < .05 for all). Thirty-day mortality and readmission rates were equivalent. Mortality was moderately worse for patients with stage IV ovarian cancer and stage II-III cervical cancer (P < .05) but were otherwise equivalent.

Conclusions

After adjusting for patient and tumor characteristics, women with gynecologic cancers treated at SNH receive lower-quality surgical care and equivalent medical care and a subset of these patients has modest decreases in survival.

Assessing the Quality of Microvascular Breast Reconstruction Performed in the Urban Safety-Net Setting: A Doubly Robust Regression Analysis

BACKGROUND

Safety-net hospitals serve vulnerable populations; however, care delivery may be of lower quality. Microvascular immediate breast reconstruction, relative to other breast reconstruction subtypes, is sensitive to the performance of safety-net hospitals and an important quality marker. The authors' aim was to assess the quality of care associated with safety-net hospital setting.

METHODS

The 2012 to 2014 National Inpatient Sample was used to identify patients who underwent microvascular immediate breast reconstruction after mastectomy. Primary outcomes of interest were rates of medical complications, surgical inpatient complications, and prolonged length of stay. A doubly-robust approach (i.e., propensity score and multivariate regression) was used to analyze the impact of patient and hospital-level characteristics on outcomes.

RESULTS

A total of 858 patients constituted our analytic cohort following propensity matching. There were no significant differences in the odds of surgical and medical inpatient complications among safety-net hospital patients relative to their matched counterparts. Black (OR, 2.95; p < 0.001) and uninsured patients (OR, 2.623; p = 0.032) had higher odds of surgical inpatient complications. Safety-net hospitals (OR, 1.745; p = 0.005), large bedsize hospitals (OR, 2.170; p = 0.023), and Medicaid patients (OR, 1.973; p = 0.008) had higher odds of prolonged length of stay.

CONCLUSIONS

Safety-net hospitals had comparable odds of adverse clinical outcomes but higher odds of prolonged length of stay, relative to non-safety-net hospitals. Institution-level deficiencies in staffing and clinical processes of care might underpin the latter. Ongoing financial support of these institutions will ensure delivery of needed breast cancer care to economically disadvantaged patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Characterizing the Role of U.S. Surgeons in the Provision of Palliative Care: A Systematic Review and Mixed-Methods Meta-Synthesis

CONTEXT

The provision of palliative care varies appropriately by clinical factors such as patient age and severity of disease and also varies by provider practice and specialty. Surgical patients are persistently less likely to receive palliative care than their medical counterparts for reasons that are not clear.

OBJECTIVES

We sought to characterize surgeon-specific determinants of palliative care in seriously ill and dying patients.

METHODS

We performed a systematic review of the literature focused on surgery and palliative care within PubMed, CINAHL, EMBASE, Scopus, and Ovid Medline databases from January 1, 2000 through December 31, 2016 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quantitative and qualitative studies with primary data evaluating surgeons' attitudes, knowledge, and behaviors or experiences in care for seriously ill and dying patients were selected for full review by at least two study team members based on predefined inclusion criteria. Data were extracted based on a predetermined instrument and compared across studies using thematic analysis in a meta-synthesis of qualitative and quantitative findings.

RESULTS

A total of 2589 abstracts were identified and screened, and 35 articles (26 quantitative and nine qualitative) fulfilled criteria for full review. Among these, 17 articles explored practice and attitudes of surgeons regarding palliative and end-of-life care, 11 articles assessed training in palliative care, five characterized surgical decision making, one described behaviors of surgeons caring for seriously ill and dying patients, and one explicitly identified barriers to use of palliative care. Four major themes across studies affected receipt of palliative care for surgical patients: 1) surgeons' experience and knowledge, 2) surgeons' attitudes, 3) surgeons' preferences and decision making for treatment, and 4) perceived barriers.

CONCLUSIONS

Among the articles reviewed, surgeons overall demonstrated insight into the benefits of palliative care but reported limited knowledge and comfort as well as a multitude of challenges to introducing palliative care to their patients. These findings indicate a need for wider implementation of strategies that allow optimal integration of palliative care with surgical decision making.

Protocol for a randomized trial of the effect of timing of cholecystectomy during initial admission for predicted mild gallstone pancreatitis at a safety-net hospital

Background

There is evidence-based consensus for laparoscopic cholecystectomy during index admission for predicted mild gallstone pancreatitis, defined by the absence of organ failure and of local or systemic complications. However, the optimal timing for surgery within that admission is controversial. Early cholecystectomy may shorten hospital length of stay (LOS) and increase patient satisfaction. Alternatively, it may increase operative difficulty and complications resulting in readmissions.

Methods

This trial is a single-center randomized trial of patients with predicted mild gallstone pancreatitis comparing laparoscopic cholecystectomy with intraoperative cholangiogram (IOC) at index admission within 24 hours of presentation versus after clinical resolution on clinical and patient-reported outcomes (PROs). The primary endpoint is 30-day LOS (hours) after initial presentation, which includes the index admission and readmissions. Secondary outcomes are conversion to open, complications, time from admission to cholecystectomy, initial hospital LOS, number of procedures within 30 days, 30-day readmissions, and PROs (change in Gastrointestinal Quality-of-Life Index).

Discussion

The primary goal of this research is to obtain the least biased estimate of effect of timing of cholecystectomy for mild gallstone pancreatitis on clinical and PROs; the results of this trial will be used to inform patient care locally as well as to design future multicenter effectiveness and implementation trials. This trial will provide data regarding PROs including health-related quality of life that can be used in cost-utility and cost-effectiveness analyses.

Trial registration number

NCT02806297, ClinicalTrials.gov.

Equivalent Treatment and Survival after Resection of Pancreatic Cancer at Safety-Net Hospitals

BACKGROUND

Due to disparities in access to care, patients with Medicaid or no health insurance are at risk of not receiving appropriate adjuvant treatment following resection of pancreatic cancer. We have previously shown inferior short-term outcomes following surgery at safety-net hospitals. Subsequently, we hypothesized that safety-net hospitals caring for these vulnerable populations utilize less adjuvant chemoradiation, resulting in inferior long-term outcomes.

METHODS

The American College of Surgeons National Cancer Data Base was queried for patients diagnosed with pancreatic adenocarcinoma (n = 32,296) from 1998 to 2010. Hospitals were grouped according to safety-net burden, defined as the proportion of patients with Medicaid or no insurance. The highest quartile, representing safety-net hospitals, was compared to lower-burden hospitals with regard to patient demographics, disease characteristics, surgical management, delivery of multimodal systemic therapy, and survival.

RESULTS

Patients at safety-net hospitals were less often white, had lower income, and were less educated. Safety-net hospital patients were just as likely to undergo surgical resection (OR 1.03, p = 0.73), achieving similar rates of negative surgical margins when compared to patients at medium and low burden hospitals (70% vs. 73% vs. 66%). Thirty-day mortality rates were 5.6% for high burden hospitals, 5.2% for medium burden hospitals, and 4.3% for low burden hospitals. No clinically significant differences were noted in the proportion of surgical patients receiving either chemotherapy (48% vs. 52% vs. 52%) or radiation therapy (26% vs. 30% vs. 29%) or the time between diagnosis and start of systemic therapy (58 days vs. 61 days vs. 53 days). Across safety-net burden groups, no difference was noted in stage-specific median survival (all p > 0.05) or receipt of adjuvant as opposed to neoadjuvant systemic therapy (82% vs. 85% vs. 85%). Multivariate analysis adjusting for cancer stage revealed no difference in survival for safety-net hospital patients who had surgery and survived > 30 days (HR 1.02, p = 0.63).

CONCLUSION

For patients surviving the perioperative setting following pancreatic cancer surgery, safety-net hospitals achieve equivalent long-term survival outcomes potentially due to equivalent delivery of multimodal therapy at non-safety-net hospitals. Safety-net hospitals are a crucial resource that provides quality long-term cancer treatment for vulnerable populations.

Outcomes and Costs of Managing Appendicitis at Safety-Net Hospitals

IMPORTANCE

Safety-net hospitals serve vulnerable populations with limited resources. Although complex, elective operations performed at safety-net hospitals have been associated with inferior outcomes and higher costs, it is unclear whether a similar association has been seen with common emergency general surgery performed at safety-net hospitals.

OBJECTIVE

To evaluate the association of safety-net burden with the outcomes of appendectomy.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review was conducted of all nonfederally funded hospitals in the California state inpatient database that performed appendectomies from January 1, 2005, to December 31, 2011. A total of 349 hospitals performing 274 405 nonincidental appendectomies were stratified based on safety-net burden; low-burden hospitals had the lowest quartile of patients who either had Medicaid or were uninsured (0%-14%), medium-burden hospitals had the middle 2 quartiles (15%-41%), and high-burden hospitals had the highest quartile (>42%). Data analysis was performed from August 27 to September 8, 2016.

MAIN OUTCOMES AND MEASURES

Rates of laparoscopy, perforation, negative appendectomy, morbidity, length of stay, and cost.

RESULTS

Among the 349 hospitals in the study, high-burden hospitals treated a larger proportion of black patients than did medium- and low-burden hospitals (4.5% vs 2.4% vs 2.9%; P = .01), as well as Hispanic patients (64.8% vs 27.0% vs 22.0%; P < .001) and patients with perforated appendicitis (27.6% vs 23.6% vs 23.6%; P = .005). High-burden hospitals were less likely than medium- or low-burden hospitals to use laparoscopy (51.6% vs 60.7% vs 71.9%; P < .001). There were no differences in morbidity, length of stay, or cost. Multivariable regression analysis confirmed that high-burden hospitals were more likely than low-burden hospitals to treat perforated appendicitis (log %, 0.07; 95% CI, 0.03-0.12; P = .04) and less likely to use laparoscopy (-16.9% difference; 95% CI, -26.1% to -7.6%; P < .001), while achieving similar complication rates. Multivariable analysis also confirmed that high-burden hospitals have similar costs, despite being associated with longer length of stay (relative risk, 1.17; 95% CI, 1.09-1.26; P < .001).

CONCLUSIONS AND RELEVANCE

Safety-net hospitals treat a disproportionate number of patients with advanced appendicitis while falling behind in the use of laparoscopy. Nonetheless, safety-net hospitals treat this common surgical emergency with morbidity and cost similar to that seen at other hospitals. Additional research is needed to evaluate how these outcomes are achieved to improve all surgical outcomes at underresourced hospitals.

Inequality and the health-care system in the USA

Widening economic inequality in the USA has been accompanied by increasing disparities in health outcomes. The life expectancy of the wealthiest Americans now exceeds that of the poorest by 10-15 years. This report, part of a Series on health and inequality in the USA, focuses on how the health-care system, which could reduce income-based disparities in health, instead often exacerbates them. Other articles in this Series address population health inequalities, and the health effects of racism, mass incarceration, and the Affordable Care Act (ACA). Poor Americans have worse access to care than do wealthy Americans, partly because many remain uninsured despite coverage expansions since 2010 due to the ACA. For individuals with private insurance, rising premiums and cost sharing have undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health-care resources devoted to care of the wealthy has risen. Additional reforms that move forward, rather than backward, from the ACA are sorely needed to mitigate health and health-care inequalities and reduce the financial burdens of medical care borne by non-wealthy Americans.

Surgeon Characteristics Supersede Hospital Characteristics in Mortality After Urgent Colectomy

BACKGROUND

Urgent colectomy is a common procedure with a high mortality rate that is performed by a variety of surgeons and hospitals. We investigated patient, surgeon, and hospital characteristics that predicted mortality after urgent colectomy.

METHODS

The University HealthSystem Consortium was queried for adults undergoing urgent or emergent colectomy between 2009 and 2013 (n = 50,707). Hospitals were grouped into quartiles according to risk-adjusted observed-to-expected (O/E) mortality ratios and compared using the 2013 American Hospital Association Annual Survey. Multiple logistic regression was used to determine patient and provider characteristics associated with in-hospital mortality.

RESULTS

The overall mortality rate after urgent colectomy was 9 %. Mortality rates were higher for patients with extreme severity of illness (27.6 %), lowest socioeconomic status (10.6 %), weekend admissions (10.7 %), and open (10.5 %) and total (15.8 %) colectomies. Hospitals with the lowest O/E ratios were smaller and had lower volume and less teaching intensity, but there were no significant trends with regard to financial (expenses, payroll, capital expenditures per bed) or personnel characteristics (physicians, nurses, technicians per bed). On multivariate analysis, mortality was associated with patient age (10 years: OR 1.31, p < 0.01), severity of illness (extreme: OR 34.68, p < 0.01), insurance status (Medicaid: OR 1.24, p < 0.01; uninsured: OR 1.40, p < 0.01), and weekend admission (OR 1.09, p = 0.04). Surgeon volume was associated with reduced mortality (per 10 cases: OR 0.99, p < 0.01), but hospital volume was not (per case: OR 1.00, p = 0.84).

CONCLUSIONS

Mortality is common after urgent colectomy and is associated with patient characteristics. Surgeon volume and practice patterns predicted differences in mortality, whereas hospital factors did not. These data suggest that policies focusing solely on hospital volume ignore other more important predictors of patient outcomes.

Vulnerable Hospitals and Cancer Surgery Readmissions: Insights into the Unintended Consequences of the Patient Protection and Affordable Care Act

BACKGROUND

Penalties from the Hospital Readmission Reduction Program can push financially strained, vulnerable patient-serving hospitals into additional hardship. In this study, we quantified the association between vulnerable hospitals and readmissions and examined the respective contributions of patient- and hospital-related factors.

METHODS

A total of 110,857 patients who underwent major cancer operations were identified from the 2004-2011 State Inpatient Database of California. Vulnerable hospitals were defined as either self-identified safety net hospitals (SNHs) or hospitals with a high percentage of Medicaid patients (high Medicaid hospitals [HMHs]). We used multivariable logistic regression to determine the association between vulnerable hospitals and readmission. Patient and hospital contributions to the elevation in odds of readmission were assessed by comparing estimates from models with different subsets of predictors.

RESULTS

Of the 355 hospitals, 13 were SNHs and 31 were HMHs. After adjusting for Hospital Readmission Reduction Program variables, SNHs had higher 30-day (odds ratio [OR] = 1.32; 95% CI, 1.18-1.47), 90-day (OR = 1.28; 95% CI, 1.18-1.38), and repeated readmissions (OR = 1.33; 95% CI, 1.18-1.49); HMHs also had higher 30-day (OR = 1.18; 95% CI, 1.05-1.32), 90-day (OR = 1.28; 95% CI, 1.16-1.42), and repeated readmissions (OR = 1.24; 95% CI, 1.01-1.54). Compared with patient characteristics, hospital factors accounted for a larger proportion of the increase in odds of readmission among SNHs (60% to 93% vs 24% to 39%), but a smaller proportion among HMHs (9% to 15% vs 60% to 115%).

CONCLUSIONS

Vulnerable status of hospitals is associated with higher readmission rates after major cancer surgery. These findings reinforce the call to account for socioeconomic variables in risk adjustments for hospitals who serve a disproportionate share of disadvantaged patients.