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Diaz A, Pawlik TM. Poverty and Its Impact on Surgical Care. Adv Surg 2024; 58:35-47. [PMID: 39089785 DOI: 10.1016/j.yasu.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
In this article, the authors explore the intricate relationship between poverty and surgical care, underscoring its multifaceted nature and its profound impact on access and outcomes. Poverty extends beyond financial constraints to encompass barriers related to healthcare infrastructure, geographic isolation, education, mental health, and social determinants of health, resulting in persistent disparities in access to high-quality surgical care, especially for those in persistently impoverished areas and access-sensitive surgical conditions. Additionally, the authors delve into the complex intersection of poverty, race, and ethnicity, emphasizing the heightened risks faced by minority patients in surgical care.
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Affiliation(s)
- Adrian Diaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH 43210, USA.
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McDermott GC, Monshizadeh A, Selzer F, Zhao SS, Ermann J, Katz JN. Factors Associated With Diagnostic Delay in Axial Spondyloarthritis: Impact of Clinical Factors and Social Vulnerability. Arthritis Care Res (Hoboken) 2024; 76:541-549. [PMID: 37881826 PMCID: PMC10963166 DOI: 10.1002/acr.25264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/23/2023] [Accepted: 10/23/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE Patients with axial spondyloarthritis (axSpA) often experience significant delay between symptom onset and diagnosis for reasons that are incompletely understood. We investigated associations between demographic, medical, and socioeconomic factors and axSpA diagnostic delay. METHODS We identified patients meeting modified New York criteria for ankylosing spondylitis (AS) or 2009 Assessment of Spondyloarthritis International Society criteria for axSpA in the Mass General Brigham health care system between December 1990 and October 2021. We determined the duration of diagnostic delay, defined as the duration of back pain symptoms reported at diagnosis, as well as disease manifestations and specialty care prior to diagnosis from the electronic health record. We obtained each patient's Social Vulnerability Index (SVI) by mapping their address to the US Centers for Disease Control SVI Atlas. We examined associations among disease manifestations, SVI, and diagnostic delay using ordinal logistic regression. RESULTS Among 554 patients with axSpA who had a median diagnostic delay of 3.8 years (interquartile range 1.1-10), peripheral arthritis (odds ratio [OR] 0.65, 95% confidence interval [CI] 0.45-0.93) and older age at symptom onset (OR 0.83, 95% CI 0.78-0.88 per five years) were associated with shorter delay. AS at diagnosis (OR 1.85, 95% CI 1.30-2.63), a history of uveitis prior to diagnosis (OR 2.77, 95% CI 1.73-4.52), and higher social vulnerability (defined as national SVI 80th to 99th percentiles; OR 1.99, 95% CI 1.06-3.84) were associated with longer diagnostic delay. CONCLUSION Older age at back pain onset and peripheral arthritis were associated with shorter delay, whereas uveitis was associated with longer diagnostic delay. Patients with higher socioeconomic vulnerability had longer diagnostic delay independent of clinical factors.
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Affiliation(s)
- Gregory C McDermott
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Faith Selzer
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Joerg Ermann
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jeffrey N Katz
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Diaz A, Azap L, Moazzam Z, Knight-Davis J, Pawlik TM. Association of social determinants of health International Classification of Disease, Tenth Edition clinical modification codes with outcomes for emergency general surgery and trauma admissions. Surgery 2024; 175:899-906. [PMID: 37863693 DOI: 10.1016/j.surg.2023.08.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/22/2023] [Accepted: 08/08/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Patients with Acute Care Surgery needs (ie, emergency general surgery diagnosis or trauma admission) are at particularly high risk for nonmedical patient-related factors that can be important drivers of healthcare outcomes. These social determinants of health are typically ascertained at the geographic area level (ie, county or neighborhood) rather than at the individual patient level. Recently, the International Classification of Diseases Tenth Revision, Tenth Edition created codes to capture health hazards related to patient socioeconomic and psychosocial circumstances. We sought to characterize the impact of these social determinants of health-related codes on perioperative outcomes among patients with acute care surgery needs. METHODS Patients diagnosed between 2017 and 2020 with acute care surgery needs (ie, emergency general surgery diagnosis or a trauma admission) were identified in the California Department of Healthcare Access and information Patient Discharge database. Data on concomitant social determinants of health-related codes (International Classification of Diseases Tenth Revision, Tenth Edition Z55-Z65), which designated health hazards related to socioeconomic and psychosocial (socioeconomic and psychosocial, respectively) circumstances, were obtained. After controlling for patient factors, including age, sex, race, payer type, and admitting hospital, the association of socioeconomic and psychosocial codes with perioperative outcomes and hospital disposition was analyzed. RESULTS Among 483,280 with an acute care surgery admission (emergency general surgery: n = 289,530, 59.9%; trauma: n = 193,705, 40.1%) mean age was 56.5 years (standard deviation: 21.5) and 271,911 (56.3%) individuals were male. Overall, 16,263 (3.4%) patients had a concomitant socioeconomic and psychosocial diagnosis code. The percentage of patients with a concurrent social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis increased throughout the study period from 2.6% in 2017 to 4.4% in 2020. Patients that were male (odds ratio 1.89; 95% confidence interval 1.82, 1.96), insured by Medicaid (odds ratio 5.43; 95% confidence interval 5.15, 5.72) or self-pay (odds ratio 3.04; 95% confidence interval 2.75, 3.36) all had higher odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. Black race did not have a significant association with an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis (odds ratio 0.99; 95% confidence interval 0.94, 1.04); however, Hispanic (odds ratio 0.44; 95% confidence interval 0.43, 0.46) and Asian (odds ratio 0.40; 95% confidence interval 0.36, 0.44) race/ethnicity was associated with a lower odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. After controlling for competing risk factors on multivariable analyses, the risk-adjusted probability of hospital postoperative death was 3.1% (95% confidence interval 2.8, 3.4) among patients with a social determinants of health diagnosis versus 5.9% (95% confidence interval 5.9, 6.0) (odds ratio 0.48; 95% confidence interval 0.44, 0.54) among patients without a social determinants of health diagnosis. Risk-adjusted complications were 26.7% (95% confidence interval 26.1, 37.3) among patients with a social determinants of health diagnosis compared with 31.9% (95% confidence interval 31.7, 32.0) (odds ratio 0.74; 95% confidence interval 0.71, 0.77) among patients without a social determinants of health diagnosis. CONCLUSION International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code use was low, with only 3.4% of patients having documentation of a socioeconomic and psychosocial circumstance. The presence of an International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code was not associated with greater odds of complications or death; however, it was associated with longer length of stay and higher odds of being discharged to a skilled nursing facility.
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Affiliation(s)
- Adrian Diaz
- The Ohio State University, Department of Surgery, Columbus, OH.
| | - Lovette Azap
- The Ohio State University, Department of Surgery, Columbus, OH
| | - Zorays Moazzam
- The Ohio State University, Department of Surgery, Columbus, OH
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Diaz A, Pawlik T. Association of ICD-10 Clinical Modification Codes for Social Determinants of Health with Surgical Outcomes and Hospital Charges Among Cancer Patients. Ann Surg Oncol 2024; 31:1171-1177. [PMID: 38006529 DOI: 10.1245/s10434-023-14501-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 10/11/2023] [Indexed: 11/27/2023]
Abstract
INTRODUCTION We sought to characterize the impact of social determinants of health (SDOH)-related codes on outcomes among patients with a cancer diagnosis. METHODS Patients diagnosed with lung, pancreas, colon, or rectal cancer between 2017 and 2020 were identified in the California Department of Healthcare Access and Information Patient Discharge Database. Data on concomitant SDOH-related codes (International Classification of Diseases, Tenth Revision [ICD-10] Z55-Z65) designating health hazards related to socioeconomic and psychosocial circumstances were obtained. The association of these SDOH codes with postoperative outcomes was evaluated. RESULTS Among 10,421 patients who underwent an operation from 2017 to 2020, median age was 66 years (interquartile range [IQR] 56-75) and nearly half of the cohort was male (n = 551,252.9%). In total, 102 (1%) patients had a concurrent ICD-10 SDOH diagnosis. After controlling for competing risk factors, the risk-adjusted probability of in-hospital death was 4.1% (95% confidence interval [CI] 1.0-7.2) among patients with an SDOH diagnosis compared with 2.9% (95% CI 2.5-3.2) among patients without an SDOH diagnosis (odds ratio [OR] 1.52, 95% CI 0.63-3.66; p = 0.258); postoperative complications were 27.0% (95% CI 20.0-34.1) compared with 24.9% (95% CI 24.1-25.6) among patients without an SDOH diagnosis (OR 1.15, 95% CI 0.73-1.82; p = 0.141), and length of stay was 10.6 days (95% CI 10.0-11.2) compared with 9.4 days (95% CI 9.3-9.5) among patients without an SDOH diagnosis. Patients with an SDOH diagnosis had a 5.19 (95% CI 3.23-8.34; p < 0.005) higher odds of being discharged to a skilled nursing facility versus patients without an SDOH diagnosis. CONCLUSION Uptake and utilization of ICD-10 SDOH was 1% among California patients with lung, pancreas, colon, or rectal cancer. Patients with a concomitant ICD-10 SDOH code had longer length of stay and had higher odds of being discharged to a skilled nursing facility.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University, Columbus, OH, USA.
| | - Timothy Pawlik
- Department of Surgery, The Ohio State University, Columbus, OH, USA
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Fei-Zhang DJ, Chelius DC, Sheyn AM, Rastatter JC. Large-data contextualizations of social determinant associations in pediatric head and neck cancers. Curr Opin Otolaryngol Head Neck Surg 2023; 31:424-429. [PMID: 37712774 DOI: 10.1097/moo.0000000000000931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
PURPOSE OF REVIEW Prior investigations in social determinants of health (SDoH) and their impact on pediatric head and neck cancers are limited by the narrow scope of cancer types and SDoH being studied while lacking inquiry on the interrelational contribution of varied SDoH in real-world contexts. The purpose of this review is to discuss the current research tackling these shortcomings of SDoH-based studies in head and neck cancer and to discuss means of applying these findings in prospective initiatives and implementations. RECENT FINDINGS Through leveraging contemporary, large-data analyses measuring diverse social vulnerabilities, several studies have identified comprehensive delineations of which social disparities contribute the largest quantifiable impact on the care of head and neck cancer patients. Progressing from prior SDoH-based research of the decade, these studies contextualize the effect of social vulnerabilities and have laid the foundations to begin addressing these issues in the complex, modern-day environment of interrelatedsocial factors. SUMMARY Social determinants of health markedly affect pediatric head and neck cancer care and prognosis in complex and surprising ways. Modern-day tools and analyses derived from large-data techniques have unveiled the quantifiable underpinnings of how SDoH impact these pathologies.
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Affiliation(s)
| | - Daniel C Chelius
- Department of Otolaryngology-Head and Neck Surgery, Pediatric Thyroid Tumor Program and Pediatric Head and Neck Tumor Program, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Anthony M Sheyn
- Department of Pediatric Otolaryngology, Le Bonheur Children's Hospital
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center
- Department of Pediatric Otolaryngology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee
| | - Jeff C Rastatter
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Smithson MG, McLeod MC, Al-Obaidi M, Harmon CA, Sawant A, Hardiman KM, Chu DI, Bhatia S, Williams GR, Hollis RH. Racial Differences in Aging-Related Deficits Among Older Adults With Colorectal Cancer. Dis Colon Rectum 2023; 66:1245-1253. [PMID: 37235857 PMCID: PMC10524491 DOI: 10.1097/dcr.0000000000002672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Despite the known influences of both race- and aging-related factors in colorectal cancer outcomes and mortality, limited literature is available on the intersection between race and aging-related impairments. OBJECTIVE To explore racial differences in frailty and geriatric deficit subdomains among patients with colorectal cancer. DESIGN Retrospective study using data from the Cancer and Aging Resilience Evaluation registry. SETTINGS A comprehensive cancer center in the Deep South. PATIENTS Older adults (aged ≥60 years) with colorectal cancer. MAIN OUTCOME MEASURES Measure of frailty and geriatric assessment subdomains of physical function, functional status, cognitive complaints, psychological function, and health-related quality of life. RESULTS Black patients lived in areas with a higher social vulnerability index compared to White patients (0.69 vs 0.49; p < 0.01) and had limited social support more often (54.5% vs 34.9%; p = 0.01). After adjustment for age, cancer stage, comorbidities, and social vulnerability index, Black patients were found to have a higher rate of frailty than White patients (adjusted OR 3.77; 95% CI, 1.76-8.18; p = 0.01). In addition, Black patients had more physical limitations (walking 1 block: adjusted OR 1.93; 95% CI, 1.02-3.69; p = 0.04), functional limitations (activities of daily living: adjusted OR 3.21; 95% CI, 1.42-7.24; p = 0.01), and deficits in health-related quality of life (poor global self-reported health: adjusted OR 2.45; 95% CI, 1.23-5.13; p = 0.01). Similar findings were shown after stratification by stage I to III vs IV. LIMITATIONS Retrospective study at a single institution. CONCLUSIONS Among older patients with colorectal cancer, Black patients were more likely to be frail than White patients, with deficits observed specifically in physical function, functional status, and health-related quality of life. Geriatric assessment may provide an important tool in addressing racial inequities in colorectal cancer. DIFERENCIAS RACIALES EN LOS DFICITS RELACIONADOS CON EL ENVEJECIMIENTO ENTRE ADULTOS MAYORES CON CNCER COLORRECTAL ANTECEDENTES: A pesar de las influencias conocidas de los factores relacionados con la raza y el envejecimiento en los resultados y la mortalidad del cáncer colorectal, hay muy poca literatura sobre la intersección entre los impedimentos relacionados con la raza y el envejecimiento.OBJETIVO: El objetivo era explorar las diferencias raciales en los subdominios de fragilidad y déficit geriátrico entre los pacientes con cáncer colorectal.DISEÑO: Estudio retrospectivo utilizando datos del registro Cancer and Aging Resilience Evaluation.AJUSTES: Un centro oncológico integral en el Sur Profundo.PACIENTES: Adultos mayores (≥60 años) con cáncer colorrectal de raza Negra o Blanca.PRINCIPALES MEDIDAS DE RESULTADO: Medida compuesta de fragilidad y subdominios de evaluación geriátrica de función física, estado funcional, quejas cognitivas, función psicológica y calidad de vida relacionada con la salud.RESULTADOS: De los 304 pacientes incluidos, el 21,7% (n = 66) eran negros y la edad media era de 69 años. Los pacientes negros vivían en áreas con un índice de vulnerabilidad social (SVI) más alto en comparación con los pacientes blancos (SVI 0,69 vs 0,49; p < 0,01) y con mayor frecuencia tenían apoyo social limitado (54,5% vs 34,9%; p = 0,01). Después de ajustar por edad, estadio del cáncer, comorbilidades y SVI, los pacientes de raza negra tenían una mayor tasa de fragilidad en comparación con los pacientes de raza blanca (ORa 3,77, IC del 95%: 1,76-8,18; p = 0,01). Además, los pacientes negros tenían más limitaciones físicas (caminar 1 cuadra: ORa 1,93, IC 95% 1,02-3,69; p = 0,04), limitaciones funcionales (actividades de la vida diaria: ORa 3,21, IC 95% 1,42-7,24; p = 0,01 ) y déficits en la calidad de vida relacionada con la salud (mala salud global autoinformada: ORa 2,45, IC 95% 1,23-5,13; p = 0,01). Las quejas cognitivas y las funciones psicológicas no difirieron según la raza (p > 0,05). Se mostraron hallazgos similares después de la estratificación por estadio I-III frente a IV.LIMITACIONES: Estudio retrospectivo en una sola institución.CONCLUSIONES: Entre los pacientes mayores con cáncer colorrectal, los pacientes negros tenían más probabilidades que los pacientes blancos de ser frágiles, observándose déficits específicamente en la función física, el estado funcional y la calidad de vida relacionada con la salud. La evaluación geriátrica puede proporcionar una herramienta importante para abordar las desigualdades raciales en el cáncer colorrectal.
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Affiliation(s)
- Mary G Smithson
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - M Chandler McLeod
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mustafa Al-Obaidi
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christian A Harmon
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Arundhati Sawant
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Karin M Hardiman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Surgery, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Daniel I Chu
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Grant R Williams
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert H Hollis
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
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Li Q, Liu H, Gao Q, Xue F, Fu J, Li M, Yuan J, Chen C, Zhang D, Geng Z. Textbook outcome in gallbladder carcinoma after curative-intent resection: a 10-year retrospective single-center study. Chin Med J (Engl) 2023:00029330-990000000-00607. [PMID: 37166217 DOI: 10.1097/cm9.0000000000002695] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Textbook outcome (TO) can guide decision-making among patients and clinicians during preoperative patient selection and postoperative quality improvement. We explored the factors associated with achieving a TO for gallbladder carcinoma (GBC) after curative-intent resection and analyzed the effect of adjuvant chemotherapy (ACT) on TO and non-TO patients. METHODS A total of 540 patients who underwent curative-intent resection for GBC at the Department of Hepatobiliary Surgery of the First Affiliated Hospital of Xi'an Jiaotong University from January 2011 to December 2020 were retrospectively analyzed. Multivariable logistic regression was used to investigate the factors associated with TO. RESULTS Among 540 patients with GBC who underwent curative-intent resection, 223 patients (41.3%) achieved a TO. The incidence of TO ranged from 19.0% to 51.0% across the study period, with a slightly increasing trend over the study period. The multivariate analysis showed that non-TO was an independent risk factor for prognosis among GBC patients after resection (P =0.003). Age ≤60 years (P =0.016), total bilirubin (TBIL) level ≤34.1 μmol/L (P <0.001), well-differentiated tumor (P =0.008), no liver involvement (P <0.001), and T1-2 stage disease (P =0.006) were independently associated with achieving a TO for GBC after resection. Before and after propensity score matching (PSM), the overall survival outcomes of non-TO GBC patients who received ACT and those who did not were statistically significant; ACT improved the prognosis of patients in the non-TO group (P <0.050). CONCLUSION Achieving a TO is associated with a better long-term prognosis among GBC patients after curative-intent resection, and ACT can improve the prognosis of those with non-TO.
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Affiliation(s)
- Qi Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Hengchao Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Qi Gao
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Feng Xue
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Jialu Fu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
- Department of Pediatric Surgery, The Second Affiliated Hospital of Xi''an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Mengke Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Jiawei Yuan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Chen Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Dong Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Zhimin Geng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
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Devin CL, Shaffer VO. Social Determinants of Health and Impact in Perioperative Space. Clin Colon Rectal Surg 2023; 36:206-209. [PMID: 37113281 PMCID: PMC10125291 DOI: 10.1055/s-0043-1761155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The Centers for Disease Control and Prevention (CDC) defines the social determinants of health (SDOH) as "the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a range of health, functioning, and quality-of-life outcomes and risks," which includes economic stability, access to quality health care, and physical environment. There is increasing evidence that SDOH have an impact in shaping a patient's access and recovery from surgery. This review evaluates the role surgeons play in reducing these disparities.
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Affiliation(s)
- Courtney L. Devin
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Virginia O. Shaffer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Moazzam Z, Lima HA, Endo Y, Alaimo L, Ejaz A, Dillhoff M, Cloyd J, Pawlik TM. The implications of fragmented practice in hepatopancreatic surgery. Surgery 2023; 173:1391-1397. [PMID: 36907781 DOI: 10.1016/j.surg.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/09/2023] [Accepted: 02/06/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Familiarity with the surgical work environment has been demonstrated to improve outcomes. We sought to investigate the impact of the rate of fragmented practice on textbook outcomes, a validated composite outcome representing an "optimal" postoperative course. METHODS Patients who underwent a hepatic or pancreatic surgical procedure between 2013 and 2017 were identified from the Medicare Standard Analytic Files. The rate of fragmented practice was defined as the surgeon's volume over the study period relative to the number of facilities practiced at. The association between the rate of fragmented practice and textbook outcomes was assessed using multivariable logistic regression. RESULTS A total of 37,599 patients were included (pancreatic: n = 23,701, 63.0%; hepatic: n = 13,898, 37.0%). After controlling for relevant characteristics, patients who underwent surgery by surgeons in higher rate of fragmented practice categories had lower odds of achieving a textbook outcome (reference: low rate of fragmented practice; intermediate rate of fragmented practice: odds ratio = 0.88 [95% confidence interval 0.84-0.93]; high rate of fragmented practice: odds ratio = 0.58 [95% confidence interval 0.54-0.61]) (both P < .001). Of note, the adverse effect of a high rate of fragmented practice on the achievement of textbook outcomes remained substantial, regardless of the county-level social vulnerability index [high rate of fragmented practice; low social vulnerability index: odds ratio = 0.58 (95% confidence interval 0.52-0.66); intermediate social vulnerability index: odds ratio = 0.56 (95% confidence interval 0.52-0.61); high social vulnerability index: odds ratio = 0.60 (95% confidence interval 0.54-0.68)] (all P < .001). Patients in intermediate and high social vulnerability index counties had 19% and 37% greater odds of undergoing surgery by a high rate of fragmented practice surgeon (reference: low social vulnerability index; intermediate social vulnerability index: odds ratio = 1.19 [95% confidence interval 1.12-1.26]; high social vulnerability index: odds ratio = 1.37 [95% confidence interval 1.28-1.46]). CONCLUSION Owing to the impact of the rate of fragmented practice on postoperative outcomes, decreasing fragmentation of care may be an important target for quality initiatives and a means to alleviate social disparities in surgical care.
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Affiliation(s)
- Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/ZoraysM
| | - Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/HLimaSurg
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/YutakaEndoSurg
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/LauraAlaimo5
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/AEjaz85
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/mary_dillhoff
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/jcloydmd
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Chen Q, Diaz A, Beane J, Dillhoff M, Cloyd J, Ejaz A, Pawlik TM. Achieving an optimal textbook outcome following pancreatic resection: The impact of surgeon specific experience in achieving high quality outcomes. Am J Surg 2023; 225:499-503. [PMID: 36446682 DOI: 10.1016/j.amjsurg.2022.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/11/2022] [Accepted: 11/17/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The interplay of patient-, procedural, and provider-level factors on the ability to achieve a textbook outcome(TO) remain poorly defined. METHODS The Medicare Standard Analytical Files from 2013 to 2017 were used to identify beneficiaries who underwent pancreatic surgery. Multivariable logistic regression with mixed effects was used to examine the role of the individual surgeon relative to patient- and procedural-factors to achieve a TO. RESULTS Among 20,902 patients who underwent pancreatic resection, median age was 72 years (IQR:68-77); roughly one-half of the cohort was female(47,4%) and the majority was White (89.3%). After controlling for patient- and procedure-related characteristics, there was 35% variation in odds of experiencing a TO relative to the specific individual surgeon who performed the operation (OR:1.35, 95%CI:1.29-1.41). Patients who underwent pancreatectomy by a bottom TO quartile surgeon had a higher observed/expected ratio for each component of TO including post-operative complication (OR:2.62, 95%CI:2.11-3.25), prolonged LOS (OR:3.36, 95%CI:2.67-4.22), 90-day readmission (OR:2.08, 95%CI:1.68-2.56), and 90-day mortality (OR:3.29, 95% CI:2.35-4.63) compared with patients treated by a high TO quartile surgeon. CONCLUSION The likelihood of achieving a TO after pancreatic resection was markedly influenced by the individual treating surgeon even after controlling for patient- and procedure-level factors.
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Affiliation(s)
- Qinyu Chen
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, USA
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, USA
| | - Joal Beane
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, USA.
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11
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Zhang Y, Kunnath N, Dimick JB, Scott JW, Ibrahim AM. Social Vulnerability and Emergency General Surgery among Medicare Beneficiaries. J Am Coll Surg 2023; 236:208-217. [PMID: 36519918 PMCID: PMC9764237 DOI: 10.1097/xcs.0000000000000429] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although the Social Vulnerability Index (SVI) was created to identify vulnerable populations after unexpected natural disasters, its ability to identify similar groups of patients undergoing unexpected emergency surgical procedures is unknown. We sought to examine the association between SVI and outcomes after emergency general surgery. STUDY DESIGN This study is a cross-sectional review of 887,193 Medicare beneficiaries who underwent 1 of 4 common emergency general surgery procedures (appendectomy, cholecystectomy, colectomy, and ventral hernia repair) performed in the urgent or emergent setting between 2014 and 2018. These data were merged with the SVI at the census-track level of residence. Risk-adjusted outcomes (30-day mortality, serious complications, readmission) were evaluated using a logistic regression model accounting for age, sex, comorbidity, year, procedure type, and hospital characteristics between high and low social vulnerability quintiles and within the 4 SVI subthemes (socioeconomic status; household composition and disability; minority status and language; and housing type and transportation). RESULTS Compared with beneficiaries with low social vulnerability, Medicare beneficiaries living in areas of high social vulnerability experienced higher rates of 30-day mortality (8.56% vs 8.08%; adjusted odds ratio 1.07; p < 0.001), serious complications (20.71% vs 18.40%; adjusted odds ratio 1.17; p < 0.001), and readmissions (16.09% vs 15.03%; adjusted odds ratio 1.08; p < 0.001). This pattern of differential outcomes was present in subgroup analysis of all 4 SVI subthemes but was greatest in the socioeconomic status and household composition and disability subthemes. CONCLUSIONS National efforts to support patients with high social vulnerability from natural disasters may be well aligned with efforts to identify communities that are particularly vulnerable to worse postoperative outcomes after emergency general surgery. Policies targeting structural barriers related to household composition and socioeconomic status may help alleviate these disparities.
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Affiliation(s)
- Yuqi Zhang
- National Clinician Scholars Program at the Clinical Research Training Program, Duke University, Durham, North Carolina 27705, USA
- Department of Surgery, Yale University, New Haven, Connecticut 06511, USA
| | - Nicholas Kunnath
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - John W Scott
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Andrew M Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan 48109, USA
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12
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Zhang Y, Kunnath N, Dimick JB, Scott JW, Diaz A, Ibrahim AM. Social Vulnerability And Outcomes For Access-Sensitive Surgical Conditions Among Medicare Beneficiaries. Health Aff (Millwood) 2022; 41:671-679. [PMID: 35500193 DOI: 10.1377/hlthaff.2021.01615] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Concerns have been raised over wide variation in rates of unplanned (emergency or urgent) surgery for access-sensitive surgical conditions-diagnoses requiring surgery that preferably is planned (elective) but, when access is limited, may be delayed until worsening symptoms require riskier and costlier unplanned surgery. Yet little is known about geographic and community-level factors that may increase the likelihood of unplanned surgery with adverse outcomes. We examined the relationship between community-level social vulnerability and rates of unplanned surgery for three access-sensitive conditions in 2014-18 among fee-for-service Medicare beneficiaries ages 65-99. Compared with patients from communities with the lowest social vulnerability, those from communities with the highest vulnerability were more likely, overall, to undergo unplanned surgery (36.2 percent versus 33.5 percent). They were also more likely to experience worse outcomes largely attributable to differential rates of unplanned surgery, including higher rates of mortality (5.4 percent versus 5.0 percent) and additional surgery within thirty days (19.6 percent versus 18.1 percent). Our findings suggest that policy addressing community-level social vulnerability may mitigate the observed differences in surgical procedures and outcomes for access-sensitive conditions.
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Affiliation(s)
- Yuqi Zhang
- Yuqi Zhang , Duke University, Durham, North Carolina
| | | | | | | | | | - Andrew M Ibrahim
- Andrew M. Ibrahim, University of Michigan, and HOK, Chicago, Illinois
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