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Goldberg ZN, Jain A, Wu R, Cognetti DM, Goldman RA. Social Determinants of Health Impact Complications Following Free-Flap Reconstruction for Head and Neck Cancer. Otolaryngol Head Neck Surg 2024. [PMID: 39189141 DOI: 10.1002/ohn.953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 08/01/2024] [Accepted: 08/10/2024] [Indexed: 08/28/2024]
Abstract
OBJECTIVE Head and neck cancers (HNCs) have increased in prevalence and often require free-flap reconstruction (FFR) after tumor ablation. Postoperative complications following FFR can be high, occurring in as many as 48% and 71% of cases. HNC patients also have many disparities in Social Determinants of Health (SDOH), but the potential impact of SDOH disparities on postoperative complications following FFR has not been formally assessed. STUDY DESIGN Retrospective cohort review. SETTING Academic Tertiary Care Institution in Northeast United States. METHODS Patients that underwent head and neck FFR between January 2018 and December 2021 were analyzed to determine associations between quartiles of the national Area Deprivation Index (ADI), a proxy for SDOH disparity, and various medical and surgical postoperative complications. Associations were assessed using χ2 analysis. RESULTS Two hundred four patients were included in the study, and 61 patients had 97 complications. Significant associations between higher national ADI quartile and incidence of several postoperative complications were identified, including any surgical complication (P = .0419), wound dehiscence (P = .0494), myocardial infarction (MI) (P = .0215), and sepsis (P = .0464). CONCLUSION There are significant associations between SDOH disparities and postoperative surgical complications, wound dehiscence, MI, and sepsis following head and neck FFR. Addressing SDOH disparities in HNC is pivotal to enhance postoperative outcomes and promote holistic patient care.
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Affiliation(s)
- Zachary N Goldberg
- Department of Otolaryngology-Head and Neck Surgery, Boston University Medical Center, Boston, Massachusetts, USA
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Amiti Jain
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Richard Wu
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - David M Cognetti
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard A Goldman
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Pecorari IL, Reynolds JA, Agarwal V. The Relationship Between Race, Social Vulnerability Index, and Clinical Follow-Up After Surgical Resection of Pituitary Tumors. World Neurosurg 2024:S1878-8750(24)01362-7. [PMID: 39116941 DOI: 10.1016/j.wneu.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/31/2024] [Accepted: 08/01/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVE Socioeconomic status and race have been found to influence patient outcomes for various cancer subtypes. In particular, minority and economically vulnerable patients present with more advanced disease and experience decreased survival compared to others. The aim of this study was to analyze the association between demographic or socioeconomic variables and rates of postsurgical follow-up after pituitary neuroendocrine tumor (PitNET) resection. METHODS A retrospective review was completed for patients with PitNETs who underwent surgery between 2018 and 2021. Patient demographics and information related to postoperative appointments and magnetic resonance imagings were obtained. Social vulnerability index (SVI) scores were recorded from the Centers for Disease Control based on nationwide census tracts. RESULTS One hundred and sixteen patients were included in the analysis (57 males). In this cohort, 50% were Black, 34% Hispanic, 9% White, and 1% Asian. The mean overall SVI score was 0.81 ± 0.23. The mean number of canceled appointments was significantly higher in the moderate-high/high SVI group (P = 0.034). Additionally, 30% of patients with moderate-high/high SVI had ≥2 canceled follow-up visits compared to 0% among patients with low/low-moderate SVI (P = 0.035). On average, White patients were less likely than non-White patients to have at least one canceled follow-up appointment (P = 0.048). CONCLUSIONS Black patients and those with high social vulnerability have decreased rates of follow-up after PitNET resection. Follow-up delays can lead to failed identification of tumor recurrence, potentially resulting in more advanced disease by the time medical care is reinitiated and increasing rates of patient morbidity and mortality. As a result, further work is needed to address and bridge these care gaps.
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Affiliation(s)
- Isabella L Pecorari
- Department of Neurological Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA.
| | - Joshua A Reynolds
- Department of Neurological Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Vijay Agarwal
- Department of Neurological Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
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Umman V, Girgin T, Baki BE, Bozbiyik O, Akbulut S, Yoldas T. Impact of pandemic and socioeconomic influences on decision-making for emergency ostomy procedures: Key factors affecting hospital visit decisions. Medicine (Baltimore) 2024; 103:e38706. [PMID: 38941379 DOI: 10.1097/md.0000000000038706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2024] Open
Abstract
Emergency surgeries are linked with increased morbidity and reduced life expectancy, often associated with low socioeconomic status, limited access to healthcare, and delayed hospital admissions. While the influence of socioeconomic status on elective surgery outcomes is well-established, its impact on emergency surgeries, including ostomy creation and closure, is less clear. This study aimed to explore how the pandemic and socioeconomic status affect emergency ostomy procedures, seeking to determine which has a greater effect. It emphasizes the importance of considering socioeconomic factors in patient care pathways for ostomy procedures. A total of 542 patients who underwent emergency ostomy formation between 2016 and 2022 were retrospectively analyzed and divided into pre-pandemic and pandemic periods. The pre-pandemic and pandemic periods were compared between themselves and against each other. Demographic data (age and sex), comorbidities, socioeconomic status, etiology of the primary disease, type of surgery, stoma type, length of hospital stay, ostomy closure time, and postoperative complications were retrospectively analyzed for all patients. In total, 290 (53%) patients underwent surgery during the pandemic period, whereas 252 (47%) underwent surgery during the pre-pandemic period. Emergency surgery was performed for malignancy in 366 (67%) patients. The number of days patients underwent ostomy closure was significantly higher in the low-income group (P = .038, 95% CI: 293,2, 386-945). The risk of failure of stoma closure was 3-fold (95% CI: 1.8-5.2) in patients with metastasis. The risk of mortality was 12.4-fold (95% CI: 6.5-23.7) when there was failure of stoma closure. When compared to pandemic period, the mortality risk was 6.3-fold (95% CI: 3.9-10.2) in pre-pandemic period. Pandemic patients had a shorter hospital stay than before the pandemic (P = .044). A high socioeconomic status was significantly associated with early hospital admission for ostomy closure, and lower probability of mortality. More metastases and perforations were observed during the pandemic period and mortality was increased during pandemic and in patients without ostomy closure. The socioeconomic status lost its effect in cases of emergency ostomy creation and had no impact on length of hospital stay in either the pre-pandemic or pandemic period.
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Affiliation(s)
- Veysel Umman
- Ege University, School of Medicine, Department of General Surgery, İzmir, Turkey
| | - Tolga Girgin
- Ege University, School of Medicine, Department of General Surgery, İzmir, Turkey
| | - Bahadir Emre Baki
- Ege University, School of Medicine, Department of General Surgery, İzmir, Turkey
| | - Osman Bozbiyik
- Ege University, School of Medicine, Department of General Surgery, İzmir, Turkey
| | - Sami Akbulut
- Inonu University, School of Medicine, Department of General Surgery, Malatya, Turkey
| | - Tayfun Yoldas
- Ege University, School of Medicine, Department of General Surgery, İzmir, Turkey
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Agarwal N, DiGiorgio A, Michalopoulos GD, Letchuman V, Chan AK, Shabani S, Lavadi RS, Lu DC, Wang MY, Haid RW, Knightly JJ, Sherrod BA, Gottfried ON, Shaffrey CI, Goldberg JL, Virk MS, Hussain I, Glassman SD, Shaffrey ME, Park P, Foley KT, Pennicooke B, Coric D, Upadhyaya C, Potts EA, Tumialán LM, Fu KMG, Asher AL, Bisson EF, Chou D, Bydon M, Mummaneni PV. Impact of Educational Background on Preoperative Disease Severity and Postoperative Outcomes Among Patients With Cervical Spondylotic Myelopathy. Clin Spine Surg 2024; 37:E137-E146. [PMID: 38102749 DOI: 10.1097/bsd.0000000000001557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 10/03/2023] [Indexed: 12/17/2023]
Abstract
STUDY DESIGN Retrospective review of a prospectively maintained database. OBJECTIVE Assess differences in preoperative status and postoperative outcomes among patients of different educational backgrounds undergoing surgical management of cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA Patient education level (EL) has been suggested to correlate with health literacy, disease perception, socioeconomic status (SES), and access to health care. METHODS The CSM data set of the Quality Outcomes Database (QOD) was queried for patients undergoing surgical management of CSM. EL was grouped as high school or below, graduate-level, and postgraduate level. The association of EL with baseline disease severity (per patient-reported outcome measures), symptoms >3 or ≤3 months, and 24-month patient-reported outcome measures were evaluated. RESULTS Among 1141 patients with CSM, 509 (44.6%) had an EL of high school or below, 471 (41.3%) had a graduate degree, and 161 (14.1%) had obtained postgraduate education. Lower EL was statistically significantly associated with symptom duration of >3 months (odds ratio=1.68), higher arm pain numeric rating scale (NRS) (coefficient=0.5), and higher neck pain NRS (coefficient=0.79). Patients with postgraduate education had statistically significantly lower Neck Disability Index (NDI) scores (coefficient=-7.17), lower arm pain scores (coefficient=-1), and higher quality-adjusted life-years (QALY) scores (coefficient=0.06). Twenty-four months after surgery, patients of lower EL had higher NDI scores, higher pain NRS scores, and lower QALY scores ( P <0.05 in all analyses). CONCLUSIONS Among patients undergoing surgical management for CSM, those reporting a lower educational level tended to present with longer symptom duration, more disease-inflicted disability and pain, and lower QALY scores. As such, patients of a lower EL are a potentially vulnerable subpopulation, and their health literacy and access to care should be prioritized.
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Affiliation(s)
- Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh School of Medicine
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anthony DiGiorgio
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | | | - Vijay Letchuman
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Andrew K Chan
- Department of Neurosurgery, Columbia University Irving Medical Center, New York City, NY
| | - Saman Shabani
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Raj Swaroop Lavadi
- Department of Neurological Surgery, University of Pittsburgh School of Medicine
| | - Daniel C Lu
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami, Miami, FL
| | | | | | | | | | | | - Jacob L Goldberg
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Michael S Virk
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | | | - Mark E Shaffrey
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Paul Park
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, University of Tennessee, Memphis, TN
| | - Kevin T Foley
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, University of Tennessee, Memphis, TN
| | - Brenton Pennicooke
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Domagoj Coric
- Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte
| | - Cheerag Upadhyaya
- Department of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Eric A Potts
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, IN
| | - Luis M Tumialán
- Department of Neurosurgery, Barrow Neurologic Institute, Phoenix, AZ
| | - Kai-Ming G Fu
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Anthony L Asher
- Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte
| | - Erica F Bisson
- Department of Neurosurgery, University of Utah, Salt Lake City, UT
| | - Dean Chou
- Department of Neurosurgery, Columbia University Irving Medical Center, New York City, NY
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
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Thornley P, Garner S, Rogers KJ, Yorgova P, Gabos PG, Shah SA. Socioeconomic, Racial, and Insurance Disparities in Clinical Outcomes After Surgery Among Patients With Idiopathic Scoliosis. J Pediatr Orthop 2024; 44:e163-e167. [PMID: 37867376 DOI: 10.1097/bpo.0000000000002551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Socioeconomic status (SES), race, and insurance type correlate with initial curve severity for patients with idiopathic scoliosis, but less is known regarding how these variables impact surgical outcomes. The objectives of this study were to determine the influence of SES, race, and insurance on preoperative appointment attendance, likelihood of obtaining a preoperative second opinion, brace prescription, missed 6 or 12-month postsurgical appointments, incidence of emergency department visits 0 to 90 days after surgery, and major complications within a year of surgery. METHODS A review of 421 patients diagnosed with idiopathic scoliosis who underwent surgery at a single high-volume pediatric spinal deformity institution between May 2015 and October 2021 was conducted. Area Deprivation Index, a quantitative measure of SES, was collected. Scores were stratified by quartile; higher scores indicated a lower SES. χ 2 tests for correlation were performed to determine whether clinical outcomes were dependent upon Area Deprivation Index, race, or insurance type; P ≤0.05 was significant. RESULTS The sample was 313 Caucasian (74%), 69 (16%) black, and 39 (9.3%) other patients. More patients had private versus public insurance (80% vs 20%) and were of higher SES. The likelihood of missing preoperative appointments was higher for black patients ( P = 0.037). Those with lower SES missed more postoperative appointments and received less bracing and second opinions ( P = 0.038, P = 0.017, P = 0.008, respectively). Being black and publicly insured correlated with fewer brace prescriptions ( P < 0.001, P = 0.050) and decreased rates of obtaining second opinions ( P = 0.004, P = 0.001). CONCLUSION Patients with idiopathic scoliosis surgery who were Caucasian, privately insured, and of higher SES were more likely to seek preoperative second opinions, be prescribed a brace, and attend postoperative appointments. Recognition of the inherent health care disparities prevalent within each pediatric spine surgery referral region is imperative to better inform local and national institutional level programs to educate and assist patients and families most at risk for disparate access to scoliosis care. LEVEL OF EVIDENCE Level III; retrospective case-control study.
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Affiliation(s)
- Patrick Thornley
- Department of Orthopaedics, Nemours Children's Health, Wilmington, DE
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Schold JD, Huml AM, Husain SA, Poggio ED, Buchalter RB, Lopez R, Kaplan B, Mohan S. Deceased donor kidneys from higher distressed communities are significantly less likely to be utilized for transplantation. Am J Transplant 2023; 23:1723-1732. [PMID: 37001643 DOI: 10.1016/j.ajt.2023.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023]
Abstract
The proportion of kidneys procured for transplantation but not utilized exceeds 20% in the United States. Factors associated with nonutilization are complex, and further understanding of novel causes are critically important. We used the national Scientific Registry of Transplant Recipients data (2010-2022) to evaluate associations of Distressed Community Index (DCI) of deceased donor residence and likelihood of kidney nonutilization (n = 209 413). Deceased donors from higher distressed communities were younger, had an increased history of hypertension and diabetes, were CDC high-risk, and had higher terminal creatinine and donation after brain death. Mechanisms and circumstances of death varied significantly by DCI. The proportion of kidney nonutilization was 19.9%, which increased by DCI quintile (Q1 = 18.1% to Q5 = 21.6%). The adjusted odds ratio of nonutilization from the highest quintile DCI communities was 1.22 (95% CI = 1.16-1.28; reference = lowest DCI), which persisted stratified by donor race. Donors from highly distressed communities were highly variable by the donor service area (range: 1%-51%; median = 21%). There was no increased risk for delayed graft function or death-censored graft loss by donor DCI but modest increased adjusted hazard for overall graft loss (high DCI = 1.05; 95% CI = 1.01-1.10; reference = lowest DCI). Results indicate that donor residential distress is associated with significantly higher rates of donor kidney nonutilization with notable regional variation and minimal impact on recipient outcomes.
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Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
| | - Anne M Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - S Ali Husain
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Emilio D Poggio
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - R Blake Buchalter
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sumit Mohan
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Epidemiology, Columbia University, New York, New York, USA
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Lopez R, Mohan S, Schold JD. Population Characteristics and Organ Procurement Organization Performance Metrics. JAMA Netw Open 2023; 6:e2336749. [PMID: 37787992 PMCID: PMC10548299 DOI: 10.1001/jamanetworkopen.2023.36749] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 08/25/2023] [Indexed: 10/04/2023] Open
Abstract
Importance In 2020, the Centers for Medicare & Medicaid Services (CMS) issued a final rule updating the Organ Procurement Organization (OPO) Conditions for Coverage. This rule evaluates OPO performance based on an unadjusted donation rate and an age-adjusted transplant rate; however, neither considers other underlying population differences. Objective To evaluate whether adjusting for age and/or area deprivation index yields the same tier assignments as the cause, age, and location consistent (CALC) tier used by CMS. Design, Setting, and Participants This retrospective cross-sectional study examined the performance of 58 OPOs from 2018 to 2020 across the entire US. A total of 12 041 778 death records were examined from the 2017 to 2020 National Center for Health Statistics' Restricted Vital Statistics Detailed Multiple Cause of Death files; 399 530 of these met the definition of potential deceased donor. Information about 42 572 solid organ donors from the Scientific Registry of Transplant Recipients was also used. Statistical analysis was performed from January 2017 to December 2020. Exposure Area deprivation of donation service areas and age of potential donors. Main Outcome and Measures OPO performance as measured by donation and transplant rates. Results A total of 399 530 potential deceased donors and 42 572 actual solid donor organs were assigned to 1 of 58 OPOs. Age and ADI adjustment resulted in 19.0% (11 of 58) to 31.0% (18 of 58) reclassification of tier ratings for the OPOs, with 46.6% of OPOs (27 of 58) changing tier ranking at least once during the 3-year period. Between 6.9% (4 of 58) and 12.1% (7 of 58) moved into tier 1 and up to 8.6% (5 of 58) moved into tier 3. Conclusions and Relevance This cross-sectional study of population characteristics and OPO performance metrics found that adjusting for area deprivation and age significantly changed OPO measured performance and tier classifications. These findings suggest that underlying population characteristics may alter processes of care and characterize donation and transplant rates independent of OPO performance. Risk adjustment accounting for population characteristics warrants consideration in prospective policy and further evaluation of quality metrics.
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Affiliation(s)
- Rocio Lopez
- Division of Transplant Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Jesse D. Schold
- Division of Transplant Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora
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Willer BL, Mpody C, Nafiu OO. Racial Inequity in Pediatric Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2023; 13:108-116. [PMID: 37168831 PMCID: PMC10150147 DOI: 10.1007/s40140-023-00560-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 05/13/2023]
Abstract
Purpose of Review Minority health disparities have received renewed attention in the USA following several highly publicized racial injustices in 2020. Though the focus has been largely on adults, children are not immune to these inequities. By reviewing racial disparities in pediatric perioperative care, we aim to engage the anesthesia community in the fight against systemic racism. Recent Findings Minority children have higher rates of anesthetic and surgical morbidity compared to White children, including respiratory events, length of stay, hospital costs, and even death. These inequities occur across surgical specialties and environments. Summary Racial disparities in the perioperative health and management of children are ubiquitous. Herein, we will summarize recent pediatric health disparity literature, discuss some important contributors to persistent inequities, and propose avenues for anesthesiologists to impact the pursuit of equitable healthcare outcomes.
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Affiliation(s)
- Brittany L. Willer
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
| | - Olubukola O. Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
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Dhillon NK, Kufera J, Ghneim M. Emergency General Surgery Procedures in Older Adults: Where You Live Matters! Am Surg 2023:31348231160838. [PMID: 36861456 DOI: 10.1177/00031348231160838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
BACKGROUND Neighborhood location and its built environment are important social determinants of health that impact health outcomes. Older adults (OAs) represent the fastest growing population in the United States with many requiring emergency general surgery procedures (EGSPs). The aim of this study was to evaluate whether neighborhood location, represented by zip code, influences mortality and disposition in OAs undergoing EGSPs in Maryland. METHODS A retrospective review was undertaken of hospital encounters in the Maryland Health Services Cost Review Commission from 2014 to 2018 of OAs undergoing EGSPs. Older adults residing in the 50 most affluent (MANs) and 50 least affluent (LANs) neighborhoods based on zip codes were compared. Data collected included demographics, all patient-refined (APR)-severity of illness (SOI), APR-risk of mortality (ROM), Charlson Comorbidity Index, complications, mortality, and discharge to a higher level of care. RESULTS Of the 8661 OAs analyzed, 2362 (27.3%) resided in MANs and 6299 (72.7%) in LANs. Older adults in LANs were more likely to undergo EGSPs, had higher APR-SOI and APR-ROM, and experienced more complications, discharge to higher level of care, and mortality. Living in LANs was independently associated with discharge to higher level of care (OR 1.56, 95% CI: 1.38-1.77, P < .001) and increased mortality (OR 1.35, 95% CI: 1.07-1.71, P = .01). DISCUSSION Mortality and quality of life in OAs undergoing EGSPs are dependent on environmental factors likely determined by neighborhood location. These factors need to be defined and incorporated in predictive models of outcomes. Public health opportunities to improve outcomes for those who are socially disadvantaged are necessary.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Program in Trauma, University of Maryland School of Medicine, 137889R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Joseph Kufera
- National Study Center for Trauma and Emergency Medical Systems, Center for Shock, Trauma and Anesthesiology Research, 12264University of Maryland School of Medicine, Baltimore MD, USA
| | - Mira Ghneim
- Department of Surgery, Program in Trauma, University of Maryland School of Medicine, 137889R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Umemoto KK, Ananth S, Ma A, Ullal A, Ramdass PVAK, Lo PC, Vyas D. Novel Application of Hydrodissection in Laparoscopic Cholecystectomy for Gangrenous Gallbladders. J Surg Res 2023; 283:1124-1132. [PMID: 36915004 DOI: 10.1016/j.jss.2022.11.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 11/12/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Laparoscopic cholecystectomy (LC) for gangrenous gallbladders (GGBs) can be challenging and represent a significant number of LC cases, necessitating more efficacious surgical techniques. Currently, the standard treatment for GGBs is blunt dissection which can have high iatrogenic complication rates. To our knowledge, this is the first large retrospective study conducted on the novel application of hydrodissection (HD) in LCs for GGBs. METHODS In this retrospective study of 386 LCs, data were collected for patient demographics, medical comorbidities, operating time (OT), anesthesia time (AT), length of stay (LOS), estimated blood loss, conversion to open procedures, 30-day readmissions, and mortality. Patients were categorized into four groups: (1) Vyas employing HD for GGBs (VHG), (2) non-Vyas group of five surgeons not employing HD for GGBs (NVG), (3) Vyas treating non-GGBs, and (4) non-Vyas group of five surgeons treating non-GGBs. Control groups were age-matched and sex-matched. Statistical analysis used descriptive statistics, Mann-Whitney U testing, and chi-squared testing (α = 0.05). RESULTS This study demonstrated significantly decreased (P < 0.05) OT (P = 0.001), AT (P < 0.001), LOS (P = 0.015), and conversion to open procedures (P = 0.047) between the VHG and NVG groups, with HD reducing OT by 35.5% compared to blunt dissection. This study did not demonstrate significantly decreased (P > 0.05) estimated blood loss (P = 0.185) and 30-day readmissions (P = 0.531) between the VHG and NVG groups, but they were trending toward significant. There were no mortalities in this study. CONCLUSIONS HD is associated with improved surgical outcomes of LCs for GGBs demonstrated by reduced OT, AT, LOS, and conversion to open procedures. Further multi-institutional studies are needed to validate HD implementation and further dissemination.
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Affiliation(s)
- Kayla K Umemoto
- California Northstate University College of Medicine, Elk Grove, California
| | - Shahini Ananth
- California Northstate University College of Medicine, Elk Grove, California
| | - Anthony Ma
- California Northstate University College of Medicine, Elk Grove, California
| | - Anvay Ullal
- California Northstate University College of Medicine, Elk Grove, California
| | - Prakash V A K Ramdass
- St. George's University School of Medicine, Department of Public Health and Preventative Medicine, St. George's, Grenada
| | - Peter C Lo
- San Joaquin General Hospital, Department of Surgery, French Camp, California
| | - Dinesh Vyas
- California Northstate University College of Medicine, Elk Grove, California; San Joaquin General Hospital, Department of Surgery, French Camp, California; Adventist Health Dameron Hospital, Department of Surgery, Stockton, California.
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Su AY, Vinogradsky A, Wang AS, Ning Y, Abrahams E, Bacchetta M, Kurlansky P, Rosenzweig EB, Takeda K. Impact of Sex, Race, and Socioeconomic Status on Survival after Pulmonary Thromboendarterectomy for Chronic Thromboembolic Pulmonary Hypertension. Eur J Cardiothorac Surg 2022; 62:6637515. [PMID: 35809067 DOI: 10.1093/ejcts/ezac364] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/04/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Pulmonary thromboendarterectomy (PTE) is a definitive treatment for chronic thromboembolic pulmonary hypertension (CTEPH). Demographic-based disparities in PTE outcomes have not been well studied. METHODS We reviewed all patients who underwent PTE for CTEPH between 2009 and 2019 at our institution, tracking demographic information including self-identified race, preoperative characteristics, and 2-year survival. Socioeconomic status (SES) was assessed using the zip code-linked Distressed Communities Index, a validated holistic measure of community well-being. Survival was estimated using Kaplan-Meier method and factors associated with mortality were estimated using Cox regression. RESULTS Of 235 PTE patients, 101 (42.9%) were white and 87 (37.0%) were black. White patients had a higher median age at surgery (57 vs. 51 years, P = 0.035) and a lower degree of economic distress (33.6 vs. 61.2 percentile, P < 0.001). Regarding sex, 106 (45.1%) patients were male and 129 (53.6%) were female. Male patients had a higher median age (59 vs. 50 years, P = 0.004), greater rates of dyslipidaemia (34% vs. 20.2%, P = 0.025), a lower ejection fraction (55% vs. 57%, P = 0.046), and longer cross-clamp (77 vs. 67.50 min, P = 0.004) and circulatory arrest times (42 vs. 37.50 min, P = 0.007). No difference was observed in unadjusted 2-year survival after PTE between patients stratified by race and sex (P = 0.35). After adjustment for clinically relevant variables, neither SES, sex, or race were associated with mortality in Cox proportional hazard analysis. CONCLUSIONS Sex, SES, and race were not associated with adverse outcomes after PTE in our single center experience.
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Affiliation(s)
- Austin Y Su
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY
| | - Alice Vinogradsky
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY
| | - Amy S Wang
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY
| | - Yuming Ning
- Center of Innovation and Outcomes Research, Department of Surgery, Columbia University
| | - Elizabeth Abrahams
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Matthew Bacchetta
- Departments of Thoracic and Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paul Kurlansky
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY
| | - Erika B Rosenzweig
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Koji Takeda
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY
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Bonner SN, Kunnath N, Dimick JB, Ibrahim AM. Neighborhood deprivation and Medicare expenditures for common surgical procedures. Am J Surg 2022; 224:1274-1279. [PMID: 35750504 DOI: 10.1016/j.amjsurg.2022.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/01/2022] [Accepted: 06/02/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The Center of Medicare and Medicaid Services valued based payments for inpatient surgical hospitalizations are adjusted for clinical but not social risk factors. While research has shown that social risk is associated with worse surgical patient outcomes, it is unknown if inpatient surgical episode Medicare payments are affected by social risk factors. METHODS Retrospective review of Medicare beneficiaries, age 65-99, undergoing appendectomy, colectomy, hernia repair, or cholecystectomy between 2014 and 2018. Neighborhood deprivation measured by Area Deprivation Index for beneficiary census tract. We evaluated Medicare payments for a total episode of surgical care comprised of index hospitalization, physician fees, post-acute care, and readmission by beneficiary neighborhood deprivation. RESULTS A total of 809,059 patients (Women, 56.0%) and mean (SD) age of 75.7 (7.4 years were included. A total of 145,351 beneficiaries lived in the least deprived neighborhoods and 134,188 who lived in the most deprived neighborhoods. Total surgical episode spending was $2654 higher among beneficiaries from the most deprived neighborhoods compared to those from the least after risk adjustment for clinical and hospital factors. These differences were driven in part by higher rates of readmissions (12.9% vs 10.8%, P < 0.001) and post-acute care (67.8% vs. 61.2%, P < 0.001) among beneficiaries living in the most deprived neighborhoods. CONCLUSION These findings suggest that value-based payment models with inclusion of social risk adjustment may be needed for surgical cohorts. Moreover, efforts focused on investing in deprived communities may be aligned with surgical quality improvement.
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Affiliation(s)
- Sidra N Bonner
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; National Clinician Scholars Program, University of Michigan, Ann Arbor, MI, USA.
| | - Nicholas Kunnath
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Andrew M Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
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Uppal TS, Chehal PK, Fernandes G, Haw JS, Shah M, Turbow S, Rajpathak S, Narayan KMV, Ali MK. Trends and Variations in Emergency Department Use Associated With Diabetes in the US by Sociodemographic Factors, 2008-2017. JAMA Netw Open 2022; 5:e2213867. [PMID: 35612855 PMCID: PMC9133946 DOI: 10.1001/jamanetworkopen.2022.13867] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Little is known about emergency department (ED) use among people with diabetes and whether the pattern of ED use varies across geographic areas and population subgroups. OBJECTIVE To estimate recent national- and state-level trends in diabetes-related ED use overall and by race and ethnicity, rural or urban location, and insurance status. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of adults visiting the ED with a diabetes-related diagnosis used serial data from the Nationwide Emergency Department Sample, a nationally representative database, and discharge records from 11 state emergency department databases for 2008, 2011, 2014, and 2016 to 2017. Data were analyzed from March 16 to November 9, 2020. EXPOSURES Reported race and ethnicity, rural or urban location, and insurance status. Data were stratified to generate state-specific estimates. MAIN OUTCOMES AND MEASURES Rates of ED use for all-cause visits among adults with diabetes (all-cause diabetes visits) and visits with primary diagnoses of diabetes-specific complications. RESULTS A larger portion of all-cause diabetes ED visits (n = 32 433 015) were by female (56.8%) and middle-aged (mean [SD] age, 58.4 [16.3] years) adults with diabetes. Nationally, all-cause diabetes ED visits per 10 000 adults increased 55.6% (95% CI, 50.6%-60.6%), from 257.6 (95% CI, 249.9-265.3) visits in 2008 to 400.8 (95% CI, 387.6-414.0) visits in 2017. All-cause diabetes ED visits increased more for urban (58.3%; 95% CI, 52.5%-64.1%) and uninsured subgroups (75.3% [95% CI, 59.8%-90.8%]) than for their counterparts. Diabetes-specific ED visits (weighted number of 1 911 795) nationally increased slightly among all subgroups. State-specific ED use rates show wide state-to-state variations in ED use by race and ethnicity, rural or urban location, and insurance. On average across states, diabetes-specific ED use among Black patients was approximately 3 times (rate ratio, 3.09 [95% CI, 2.91-3.30]) greater than among non-Hispanic White patients, and among Hispanic patients, it was 29% greater (rate ratio, 1.29 [95% CI, 1.19-1.40]) than among non-Hispanic White patients. The mean rate of ED use among rural patients was 34% greater (rate ratio, 1.34 [95% CI, 1.26-1.44]) than among urban patients. The mean rates of ED use among patients with Medicaid (rate ratio, 6.65 [95% CI, 6.49-6.82]) and Medicare (rate ratio, 4.37 [95% CI, 4.23-4.51]) were greater than among privately insured adults. CONCLUSIONS AND RELEVANCE This study suggests that disparities in diabetes-related ED use associated with race and ethnicity, rural or urban location, and insurance status were persistent from 2008 to 2017 within and across states, as well as nationally. Further geographic and demographic-specific analyses are needed to understand the sources of inequity.
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Affiliation(s)
- Tegveer S. Uppal
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Puneet Kaur Chehal
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - J. Sonya Haw
- Division of Endocrinology and Metabolism, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Megha Shah
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Sara Turbow
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Division of General Medicine and Geriatrics, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | | | - K. M. Venkat Narayan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Mohammed K. Ali
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia
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Cain BT, Horns JJ, Huang LC, McCrum ML. Socioeconomic disadvantage is associated with greater mortality after high-risk emergency general surgery. J Trauma Acute Care Surg 2022; 92:691-700. [PMID: 34991125 PMCID: PMC8957531 DOI: 10.1097/ta.0000000000003517] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Socioeconomic disadvantage is associated with worse outcomes after elective surgery, but the effect on emergency general surgery (EGS) remains unclear. We examined the association of socioeconomic disadvantage and outcomes after EGS procedures and investigated whether admission to hospitals with comprehensive clinical and social resources mitigated this effect. METHODS Adults undergoing 1 of the 10 most burdensome high- and low-risk EGS procedures were identified in six 2014 State Inpatient Databases. Socioeconomic disadvantage was assessed using Area Deprivation Index (ADI) of patient residence. Multivariable logistic regression models adjusting for patient and hospital factors were used to evaluate the association between ADI quartile (high >75 percentile vs. low <25 percentile), and 30-day readmission, in-hospital mortality, and discharge disposition. Effect modification between ADI and (a) level 1 trauma center and (b) safety-net hospital status was tested. RESULTS A total of 103,749 patients were analyzed: 72,711 low-risk (70.1%) and 31,038 high-risk procedures (29.9%). Patients from neighborhoods with high socioeconomic disadvantage had a higher proportion with ≥3 comorbidities (41.9% vs. 32.0%), minority race/ethnicity (66.3% vs. 42.4%), and Medicaid (28.8% vs. 14.7%) and were less likely to be treated at level 1 trauma centers (18.3% vs. 27.7%; p < 0.001 for all). Adjusting for competing factors, high socioeconomic disadvantage was associated with increased in-hospital mortality after high-risk procedures (odd ratio, 1.30; 95% confidence interval, 1.01-1.66; p = 0.04) and higher odds of non-home discharge (odd ratio, 1.15; 95% confidence interval, 1.02-1.30; p = 0.03) for low-risk procedures. Socioeconomic disadvantage was not associated with 30-day readmission for either procedure group. Level 1 trauma status and safety-net hospital did not meaningfully mitigate effect of ADI for any outcome. CONCLUSION Socioeconomic disadvantage is associated with increased mortality after high-risk procedures and higher odds of non-home discharge after low-risk procedures. This effect was not mitigated by either level 1 trauma or safety-net hospitals. Interventions that specifically address the needs of socially vulnerable communities will be required to significantly improve EGS outcomes for this population. LEVEL OF EVIDENCE Prognostic and Epidemiologic, level III.
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Affiliation(s)
- Brian T Cain
- From the Department of Surgery, University of Utah, Salt Lake City, Utah
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15
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Willer BL, Mpody C, Tobias JD, Nafiu OO. Association of Race and Family Socioeconomic Status With Pediatric Postoperative Mortality. JAMA Netw Open 2022; 5:e222989. [PMID: 35302629 PMCID: PMC8933731 DOI: 10.1001/jamanetworkopen.2022.2989] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Racial disparities in postoperative outcomes have remained difficult to eliminate. It is commonly understood that socioeconomic status (SES) is an important factor associated with excess risk of postoperative morbidity and death. To date, comparable data exploring the association of family SES with pediatric postoperative mortality are unavailable, and it is unknown whether the advantage provided by higher income status is equitable across racial groups. OBJECTIVE To assess whether increasing family SES is associated with lower pediatric postoperative mortality and, if so, whether this association is equitable among Black and White children. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from 51 freestanding pediatric tertiary care hospitals across the US that reported to the Children's Hospital Association Pediatric Health Information System. The study included 1 378 111 Black and White children younger than 18 years who underwent inpatient surgical procedures between January 1, 2004, and December 31, 2020. EXPOSURES The exposures of interest were race (Black and White) and parental income quartile (used as a proxy for SES and measured by median income quartile of the zip code of residence). Race was self-reported by parents or guardians at admission or assessed by the registration team consistent with each hospital's policy and state legislation. MAIN OUTCOMES AND MEASURES The primary outcome was risk-adjusted in-hospital mortality rates by race and parental income quartile controlled for baseline covariates. To evaluate whether belonging to the highest income quartile modified the association between race and postoperative mortality, multiplicative and additive interactions were examined. RESULTS Among 1 378 111 children (773 364 [56.1%] male; mean [SD] age, 7 [6] years) who received inpatient surgical procedures during the study period, 248 464 children (18.0%) were Black, and 1 129 647 children (82.0%) were White; 211 127 children (15.3%) were Hispanic, and 825 477 (59.9%) were non-Hispanic. Only 49 541 Black children (20.3%) belonged to the highest income quartile compared with 482 758 White children (43.0%). The overall mortality rate was 1.2%, and mortality rates decreased as income quartile increased (1.4% in quartile 1 [lowest income], 1.3% in quartile 2, 1.0% in quartile 3, and 0.9% in quartile 4 [highest income]; P < .001). Among those belonging to the 3 lowest income quartiles, Black children had 33% higher odds of postoperative death compared with White children (adjusted odds ratio, 1.33; 95% CI, 1.27-1.39; P < .001). This racial disparity gap persisted among children belonging to the highest income quartile (adjusted odds ratio, 1.39; 95% CI, 1.25-1.54; P < .001). Postoperative mortality rates among Black children in the highest income quartile (1.30%; 95% CI, 1.19%-1.42%) were comparable to those of White children in the lowest income quartile (1.20%; 95% CI, 1.16%-1.25%). The interaction between Black race and income was not statistically significant on either the multiplicative scale (β for interaction = 1.04; 95% CI, 0.93-1.17; P = .45) or the additive scale (relative excess risk due to interaction = 0.01; 95% CI, -0.11 to 0.11; P > .99), suggesting no reduction in the disparity gap across increasing income levels. CONCLUSIONS AND RELEVANCE In this cohort study, increasing SES was associated with lower pediatric postoperative mortality. However, postoperative mortality rates were significantly higher among Black children in the highest SES category compared with White children in the same category, and mortality rates among Black children in the highest SES category were comparable to those of White children in the lowest SES category. These findings suggest that increasing family SES did not provide equitable advantage to Black compared with White children, and interventions that target socioeconomic inequities alone may not fully address persistent racial disparities in pediatric postoperative mortality.
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Affiliation(s)
- Brittany L Willer
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- College of Medicine, The Ohio State University, Columbus
| | - Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- College of Medicine, The Ohio State University, Columbus
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- College of Medicine, The Ohio State University, Columbus
| | - Olubukola O Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- College of Medicine, The Ohio State University, Columbus
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Bouchard ME, Kan K, Tian Y, Casale M, Smith T, De Boer C, Linton S, Abdullah F, Ghomrawi HMK. Association Between Neighborhood-Level Social Determinants of Health and Access to Pediatric Appendicitis Care. JAMA Netw Open 2022; 5:e2148865. [PMID: 35171257 PMCID: PMC8851303 DOI: 10.1001/jamanetworkopen.2021.48865] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Presenting with complicated appendicitis, which is associated with higher rates of complications and readmissions compared with simple appendicitis, may indicate delayed access to care. Although both patient-level and neighborhood-level social determinants of health are associated with access to care, little is known about the association between neighborhood factors and access to acute pediatric surgical care. OBJECTIVE To examine the association between neighborhood factors and the odds of presenting with complicated appendicitis and unplanned postdischarge health care use. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of patients aged 18 years or younger diagnosed with appendicitis was conducted. Discharge data from October 1, 2015, to September 30, 2018, were obtained from the Pediatric Health Information System Database and linked to the Child Opportunity Index (COI) 2.0 Database. Data analysis was conducted from January 1 through July 1, 2021. EXPOSURES The COI, a composite score of zip code neighborhood opportunity level information, divided into quintiles ranging from very low to very high opportunity. MAIN OUTCOMES AND MEASURES Based on COI level, the main outcome was the odds of presenting with complicated appendicitis, which was defined using the Agency for Healthcare Research and Quality-specified International Statistical Classification of Diseases, 10th Edition, Clinical Modification codes. The secondary outcome was the odds of unplanned postdischarge health care use (emergency department visits and/or readmissions) for patients with simple and with complicated appendicitis. RESULTS A total of 67 489 patients (mean [SD] age, 10.5 [3.9] years) had appendicitis, with 31 223 cases (46.3%) being complicated. A total of 1699 patients (2.5%) were Asian, 24 234 (35.9%) were Hispanic, 4447 (6.6%) were non-Hispanic Black, and 29 234 (43.3%) were non-Hispanic White; 40 549 patients (60.1%) were male; and 32 343 (47.9%) were publicly insured. Patients living in very low-COI neighborhoods had 28% higher odds of presenting with complicated appendicitis (odds ratio, 1.28; 95% CI, 1.20-1.35) compared with those in very high-COI neighborhoods. There was no significant association between COI level and unplanned postdischarge health care use (very high COI, 20.8%; very low COI, 19.1%). CONCLUSIONS AND RELEVANCE In this cohort study, children from lower-COI neighborhoods had increased odds of presenting with complicated appendicitis compared with those from higher-COI neighborhoods, even after controlling for patient-level social determinants of health factors. These findings may inform policies and programs that seek to improve access to pediatric surgical care.
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Affiliation(s)
- Megan E. Bouchard
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Kristin Kan
- Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Yao Tian
- Departments of Surgery and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mia Casale
- Population Health Analytics, Division of Data Analytics and Reporting, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Tracie Smith
- Population Health Analytics, Division of Data Analytics and Reporting, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Christopher De Boer
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Samuel Linton
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Departments of Surgery and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hassan M. K. Ghomrawi
- Departments of Surgery and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Dlott CC, Pei X, Ittner JL, Lefar SL, O'Connor MI. Intersectionality of Net Worth and Race Relative to Utilization of Total Hip and Knee Arthroplasty. J Arthroplasty 2021; 36:3060-3066.e1. [PMID: 34099350 DOI: 10.1016/j.arth.2021.04.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/18/2021] [Accepted: 04/27/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although the number of total hip arthroplasty and total knee arthroplasty (THA and TKA) increases, individuals of color continue to be less likely to undergo these procedures. Socioeconomic status may be a key influencer of THA and TKA utilization and outcomes. We explore the influence of net worth and race on THA and TKA utilization and outcomes of length of stay and readmissions using a large patient database. METHODS The StrataSphere data set, an aggregation of 49 health systems representing 209 hospitals, was used for primary THA and TKA procedures performed in the calendar year 2019. Net worth was determined from Market Vue Partners' data sources. Statistical analyses were performed to investigate relationships between net worth and patients undergoing THA or TKA. RESULTS When comparing our overall patient cohorts with the US population using Census data, we found differences in the utilization pattern indicated by index ratios most clearly in the lowest net worth categories. In the <$10K net worth category, THA and TKA index ratios were 0.51 and 0.54, respectively. In addition, we found that patients in the $100-250 and $250-500K net worth categories had increased utilization of both THA (index ratios of 1.39, 1.53) and TKA (index ratios of 1.45, 1.47) surgeries. CONCLUSION Net worth is a strong driver of disparities in utilization of THA and TKA with lower utilization of these surgeries in patients with net worth <$10K and increased utilization in patients with net worth from $100-250 and $250-500K.
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Affiliation(s)
| | - Xun Pei
- Strata Decision Technology, Chicago, IL
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Barriers to Care Among Patients With Sarcoidosis: A Qualitative Study. Ann Am Thorac Soc 2021; 18:1832-1838. [PMID: 33856968 DOI: 10.1513/annalsats.202011-1467oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Lower income patients with sarcoidosis experience worse outcomes compared to those with higher incomes. The reasons for these disparities are not well understood. OBJECTIVES To identify patient reported barriers and facilitators to optimal care among sarcoidosis patients residing in high and low median income zip codes. METHODS Patients with biopsy proven sarcoidosis who received pharmacologic within the past year and were cared for in a sarcoidosis clinic of a large, urban medical system were included. Focus groups were stratified by high and low median income zip codes. Transcriptions were analyzed utilizing grounded theory. RESULTS Five focus groups were conducted - two included patients living in zip codes with high median incomes ($84,263, IQR $79,334-$89,795) and three included patients living in zip codes with low median incomes ($27,470, IQR $22,412-27,597). Sarcoidosis patients from low-income and high-income zip codes reported remarkably similar experiences. Patients reported sarcoidosis being a burden due to the disease manifestations and adverse effects of treatment which led to compromised ability to perform their activities of daily living at home or at work. Reported barriers to care included a perceived inadequate knowledge about sarcoidosis among providers, communication barriers with providers, and high cost of treatment. Patients from low-income zip codes experienced discrimination related to race and income, which served to compound mistrust. Patients sought to overcome these barriers through self-empowerment, including independent learning, self-advocacy, medication non-adherence and use of alternative therapies. CONCLUSIONS Patients with sarcoidosis who lived in high- and low-income zip codes expressed similar overall concerns regarding sarcoidosis care. However, patients from low-income zip codes more frequently expressed concerns of racial and income discrimination. Patients from both groups addressed these barriers through self-empowerment which included not adhering to prescribed therapies. Future work should focus on the effects of culturally and socioeconomically congruent, community-engaged interventions on quality of life of patients with sarcoidosis.
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