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Coaston TN, Sakowitz S, Chervu NL, Branche C, Shuch BM, Benharash P, Revels S. Persistent racial disparities in refusal of resection in non-small cell lung cancer patients at high-volume and Black-serving institutions. Surgery 2023; 174:1428-1435. [PMID: 37821266 DOI: 10.1016/j.surg.2023.09.006] [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: 03/04/2023] [Revised: 08/29/2023] [Accepted: 09/05/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Surgical resection is the standard of care for early-stage non-small cell lung cancer. Black patients have higher surgical refusal rates than White patients. We evaluated factors associated with the refusal of resection and subsequent non-small cell lung cancer outcomes. METHODS We identified patients with non-small cell lung cancer stages IA to IIIA eligible for surgical resection (lobectomy or pneumonectomy) listed between 2004 and 2017 in the National Cancer Database. We stratified hospitals by the proportion of Black patients served and lung cancer resection volume. We used multivariable regression models to identify factors associated with refusal of resection and assessed 5-year mortality using Kaplan-Meier analysis and Cox proportional hazard modeling. RESULTS Of 221,396 patients identified, 7,753 (3.5%) refused surgery. Black race was associated with increased refusal (adjusted odds ratio 2.06, 95% confidence interval 1.90-2.22). Compared to White race, Black race was associated with increased refusal across the highest (adjusted odds ratio 2.29, 95% confidence interval 1.94-2.54), intermediate (adjusted odds ratio 2.05, 95% confidence interval 1.78-2.37), and lowest (adjusted odds ratio 1.77, 95% confidence interval 1.58-1.99) volume tertiles. Similarly, Black race was associated with increased refusal across the highest (adjusted odds ratio 1.97, 95% confidence interval 1.78-2.17), intermediate (adjusted odds ratio 2.08, 95% confidence interval 1.80-2.40), and lowest (adjusted odds ratio 1.53, 95% confidence interval 1.13-2.06) Black-serving tertiles. However, surgical resection yielded similar 5-year survival for Black and White patients. CONCLUSION Racial disparities in non-small cell lung cancer surgery refusal persist regardless of hospital volume or proportion of Black patients served. These findings suggest that a better understanding of patient and patient-provider level interventions could facilitate a better understanding of treatment decision-making.
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Affiliation(s)
- Troy N Coaston
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA. https://twitter.com/sarasakowitz
| | - Nikhil L Chervu
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Corynn Branche
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Brian M Shuch
- Institute of Urologic Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Sha'Shonda Revels
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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2
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Lin JA, Braun HJ, Schwab ME, Pierce L, Sosa JA, Wick EC. Pandemic Recovery: Persistent Disparities in Access to Elective Surgical Procedures. Ann Surg 2023; 277:57-65. [PMID: 33914483 PMCID: PMC8542562 DOI: 10.1097/sla.0000000000004848] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine potential disparities in patient access to elective procedures during the recovery phase of the COVID-19 pandemic. SUMMARY OF BACKGROUND DATA Elective surgeries during the pandemic were limited acutely. Access to surgical care was restored in a recovery phase but backlogs and societal shifts are hypothesized to impact surgical access. METHODS Adults with electronic health record orders for procedures ("procedure requests"), from March 16 to August 25, 2019 and March 16 to August 25, 2020, were included. Logistic regression was performed for requested procedures that were not scheduled. Linear regression was performed for wait time from request to scheduled or completed procedure. RESULTS The number of patients with procedure requests decreased 20.8%, from 26,789 in 2019 to 21,162 in 2020. Patients aged 36-50 and >65 years, those speaking non-English languages, those with Medicare or no insurance, and those living >100 miles away had disproportionately larger decreases. Requested procedures had significantly increased adjusted odds ratios (aORs) of not being scheduled for patients with primary languages other than English, Spanish, or Cantonese [aOR 1.60, 95% confidence interval (CI) 1.12-2.28]; unpartnered marital status (aOR 1.21, 95% CI 1.07-1.37); uninsured or self-pay (aOR 2.03, 95% CI 1.53-2.70). Significantly longer wait times were seen for patients aged 36-65 years; with Medi-Cal insurance; from ZIP codes with lower incomes; and from ZIP codes >100 miles away. CONCLUSIONS Patient access to elective surgeries decreased during the pandemic recovery phase with disparities based on patient age, language, marital status, insurance, socioeconomic status, and distance from care. Steps to address modifiable disparities have been taken.
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Affiliation(s)
- Joseph A. Lin
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Hillary J. Braun
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Marisa E. Schwab
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Logan Pierce
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Julie A. Sosa
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth C. Wick
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
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Abstract
PURPOSE OF REVIEW Despite an overall reduction in lung cancer incidence and mortality rates worldwide, Blacks still have higher mortality rates compared to Whites. There are many factors that contribute to this difference. This review seeks to highlight racial disparities in treatment and the possible reasons for these disparities. RECENT FINDINGS Factors attributing to racial disparities in lung cancer treatment include social determinants of health, differences in the administration of guideline-concordant therapy as well as molecular testing that is essential for most NSCLC patients. One way to circumvent disparities in lung cancer survivorship is to ensure equal representation of race in research at all levels that will provide insight on interventions that will address social determinants of health, differences in treatment patterns, molecular testing, and clinical trial involvement.
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Affiliation(s)
- Sharon Harrison
- Cancer Prevention and Control Program, Fox Chase Cancer Center, 333 Cottman Ave., Philadelphia, PA, 19111, USA
- African Caribbean Cancer Consortium, Philadelphia, PA, 19111, USA
| | - Julia Judd
- Department of Hematology/Oncology, Fox Chase Cancer Center, Temple University Hospital, 333 Cottman Ave., Philadelphia, PA, 19111, USA
| | - Sheray Chin
- African Caribbean Cancer Consortium, Philadelphia, PA, 19111, USA
- Department of Pathology (Division of Haematology & Oncology), Faculty of Medical Sciences, University of the West Indies, Mona, Jamaica
| | - Camille Ragin
- Cancer Prevention and Control Program, Fox Chase Cancer Center, 333 Cottman Ave., Philadelphia, PA, 19111, USA.
- African Caribbean Cancer Consortium, Philadelphia, PA, 19111, USA.
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4
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OUP accepted manuscript. JNCI Cancer Spectr 2022; 6:6522128. [DOI: 10.1093/jncics/pkac008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 11/14/2022] Open
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5
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Harrison S, Sun T, Kamel MK, Cleary C, Stiles BM, Altorki NK, Sedrakyan A. Do individual surgeon volumes affect outcomes in thoracic surgery?†. Eur J Cardiothorac Surg 2020; 56:770-777. [PMID: 30927422 DOI: 10.1093/ejcts/ezz095] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 02/20/2019] [Accepted: 02/26/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Minimum volume standards for thoracic surgical procedures have been advocated to improve outcomes. However, such standards are controversial within the thoracic surgery literature, and the methodology to determine cut points between high- and low-volume hospitals has been criticized. Furthermore, while multiple studies have examined hospital volume and its relationship with outcomes, there have been very few attempts to study this issue from the perspective of the individual thoracic surgeon. The aim of this study was to determine if surgeon volume is associated with differences in outcomes using a large state-wide database. METHODS The study utilized the New York State Department of Health Statewide Planning and Research Cooperative (SPARCS) data for analysis. Patients who underwent major lung resections including sublobar resection, lobectomy and pneumonectomy from 1995 to 2014 were included and were categorized into 3 subgroups based on the extent of resection. Patient characteristics included age, gender, race, insurance and comorbidities. Surgeon information was obtained by using a unique identifier. Average annual surgical volumes of sublobar resection, lobectomy and pneumonectomy were calculated separately and grouped into 3 categories based on the tertiles. Demographic data and comorbidities were compared between the various volume groups to analyse the resulting complications. Primary outcomes were in-hospital mortality and 30-day readmission. RESULTS There were a total of 99 576 major lung resections performed between 1995 and 2014 in the SPARCS database. Among these, the majority were wedge or segmental resections (n = 54 953, 55.2%) followed by lobectomy (n = 40 421, 40.6%) and pneumonectomy (n = 4202, 4.2%). In-hospital mortality was significantly greater for low-volume surgeons compared to high-volume surgeons for all resection groups. Additionally, low-volume surgeons had higher 30-day readmission rates for patients undergoing lobectomy and pneumonectomy. However, low-volume surgeons as a group were more likely to operate on black patients and patients with Medicaid, and black race was an independent predictor of mortality across all resection groups. The vast majority of surgeons performing lobectomy (89.5%) were in the low-volume group. CONCLUSIONS Low-volume surgeons had higher rates of in-hospital mortality compared to their high-volume counterparts. However, the vast majority of surgeons performing lobectomy (89.5%) were in the low-volume group, and low-volume surgeons operated on higher percentages of black patients. These findings suggest that minimal volume standards would significantly impact the current delivery of thoracic surgery in the US.
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Affiliation(s)
- Sebron Harrison
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
- Department of Cardiothoracic Surgery, New York Presbyterian-Brooklyn Methodist Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Tiany Sun
- Department of Health Policy and Research, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Mohamed K Kamel
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Corbin Cleary
- Department of Cardiothoracic Surgery, New York Presbyterian-Brooklyn Methodist Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Brendon M Stiles
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Nasser K Altorki
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Art Sedrakyan
- Department of Health Policy and Research, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
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Salazar AS, Sekhon S, Rohatgi KW, Nuako A, Liu J, Harriss C, Brennan E, LaBeau D, Abdalla I, Schulze C, Muenks J, Overlot D, Higgins JA, Jones LS, Swick C, Goings S, Badiu J, Walker J, Colditz GA, James AS. A stepped-wedge randomized trial protocol of a community intervention for increasing lung screening through engaging primary care providers (I-STEP). Contemp Clin Trials 2020; 91:105991. [PMID: 32184197 DOI: 10.1016/j.cct.2020.105991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/28/2020] [Accepted: 03/11/2020] [Indexed: 01/01/2023]
Abstract
Lung cancer screening with low-dose computed tomography (LDCT) reduces lung cancer mortality, yet few eligible high-risk patients receive it annually. This protocol describes a community-partnered intervention (Toolkit) designed to support primary care practices in making referrals for lung screening and guiding patients into appropriate screening pathways. This study uses a stepped-wedge implementation design. Screening centers are randomized by readiness level to enter the intervention phase in three-month "steps" with pre-intervention data serving as the control. The primary outcome is whether delivery of the Toolkit to primary care practices results in a monthly increase in number of initial LDCT screenings. Six participating centers will identify 10 practices and reach 2-3 providers per practice to train them to use the Toolkit. The Toolkit will address known barriers to screening and referral at the patient and provider levels and provide support for required elements of screening. Toolkit components include adaptable evidence-based interventions to maximize compatibility with workflows. We hypothesize that after nine months of intervention delivery, the number of initial screening per center will double. Involving 60 practices achieves 80% power at 5% level of significance. Implementation outcomes such as adoption, acceptability, feasibility, adaptation, and sustainability will be assessed through field-notes and activity logs. LDCT for lung cancer screening currently reaches a small fraction of eligible adults. To reach the full potential to reduce mortality, primary care practices are an important venue for increasing appropriate referrals. This multidisciplinary trial will encourage acceptability and sustainability by using local knowledge and promoting partnership between providers and patients. Trial registration: ClinicalTrials.gov, NCT03958253.
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Affiliation(s)
- Ana S Salazar
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8100, St. Louis, MO 63110-0193, USA.
| | | | - Karthik W Rohatgi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8100, St. Louis, MO 63110-0193, USA.
| | - Akua Nuako
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8100, St. Louis, MO 63110-0193, USA.
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8100, St. Louis, MO 63110-0193, USA.
| | - Courtney Harriss
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8100, St. Louis, MO 63110-0193, USA.
| | - Ellen Brennan
- Siteman Cancer Center at Barnes-Jewish St. Peters Hospital, 150 Entrance Way, St. Peters, MO 63376, USA.
| | - Dareld LaBeau
- Siteman Cancer Center at Barnes-Jewish St. Peters Hospital, 150 Entrance Way, St. Peters, MO 63376, USA.
| | - Ibrahim Abdalla
- Hulston Cancer Center, CoxHealth, 3850 S National, Springfield, MO 65807, USA.
| | - Christopher Schulze
- Hulston Cancer Center, CoxHealth, 3850 S National, Springfield, MO 65807, USA.
| | - Jackie Muenks
- Hulston Cancer Center, CoxHealth, 3850 S National, Springfield, MO 65807, USA.
| | - Dave Overlot
- Cancer Care Center of Decatur, Decatur Memorial Hospital, 210 W. McKinley Avenue, Decatur, IL 62526, USA.
| | - Jeri Ann Higgins
- Cancer Care Center of Decatur, Decatur Memorial Hospital, 210 W. McKinley Avenue, Decatur, IL 62526, USA.
| | - Linda S Jones
- Regional Cancer Center, Memorial Health System, 701 N 1(st), Springfield, IL 62781, USA.
| | - Colleen Swick
- Sarah Bush Lincoln Regional Cancer Center, Sarah Bush Lincoln Health System, 1001 Health Center Drive, Mattoon, IL 61938, USA.
| | - Stacia Goings
- Sarah Bush Lincoln Regional Cancer Center, Sarah Bush Lincoln Health System, 1001 Health Center Drive, Mattoon, IL 61938, USA.
| | - Jennifer Badiu
- SIH Cancer Institute, Southern Illinois Healthcare, 1400 Pin Oak Drive, Carterville, IL 62918, USA.
| | - Justin Walker
- SIH Cancer Institute, Southern Illinois Healthcare, 1400 Pin Oak Drive, Carterville, IL 62918, USA.
| | - Graham A Colditz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8100, St. Louis, MO 63110-0193, USA.
| | - Aimee S James
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8100, St. Louis, MO 63110-0193, USA.
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7
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Haque W, Aghazadeh M, Miles BJ, Satkunasivam R, Butler EB, Teh BS. Clinical benefit of treatment for metastatic renal cell cancer at high volume facilities. ANNALS OF TRANSLATIONAL MEDICINE 2019; 6:S90. [PMID: 30740411 DOI: 10.21037/atm.2018.11.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Monty Aghazadeh
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
| | - Brian J Miles
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
| | - Raj Satkunasivam
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
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8
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Chen YW, Ornstein MC, Wood LS, Allman KD, Martin A, Beach J, Gilligan T, Garcia JA, Rini BI. The association between facility case volume and overall survival in patients with metastatic renal cell carcinoma in the targeted therapy era. Urol Oncol 2018; 36:470.e19-470.e29. [DOI: 10.1016/j.urolonc.2018.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/27/2018] [Accepted: 06/27/2018] [Indexed: 12/25/2022]
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Fang CY, Tseng M. Ethnic density and cancer: A review of the evidence. Cancer 2018; 124:1877-1903. [PMID: 29411868 PMCID: PMC5920546 DOI: 10.1002/cncr.31177] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 10/24/2017] [Accepted: 11/13/2017] [Indexed: 01/04/2023]
Abstract
Accumulating data suggest that factors in the social environment may be associated with cancer-related outcomes. Ethnic density, defined as the proportion of racial/ethnic minority individuals residing in a given geographic area, is 1 of the most frequently studied social environment factors, but studies on ethnic density and cancer have yielded inconsistent findings. Thus, the objective of the current review was to summarize the extant data on ethnic density and cancer-related outcomes (cancer risk, stage at diagnosis, and mortality) with the aim of identifying pathways by which ethnic density may contribute to outcomes across populations. In general, the findings indicated an association between ethnic density and increased risk for cancers of infectious origin (eg, liver, cervical) but lower risk for breast and colorectal cancers, particularly among Hispanic and Asian Americans. Hispanic ethnic density was associated with greater odds of late-stage cancer diagnosis, whereas black ethnic density was associated with greater mortality. In addition, this review highlights several methodological and conceptual issues surrounding the measurement of ethnic neighborhoods and their available resources. Clarifying the role of neighborhood ethnic density is critical to developing a greater understanding of the health risks and benefits accompanying these environments and how they may affect racial and ethnic disparities in cancer-related outcomes. Cancer 2018;124:1877-903. © 2018 American Cancer Society.
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Affiliation(s)
- Carolyn Y Fang
- Cancer Prevention and Control Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Marilyn Tseng
- Kinesiology Department, California Polytechnic State University, San Luis Obispo, California
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10
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Burton BN, Khoche S, A'Court AM, Schmidt UH, Gabriel RA. Perioperative Risk Factors Associated With Postoperative Unplanned Intubation After Lung Resection. J Cardiothorac Vasc Anesth 2018; 32:1739-1746. [PMID: 29506893 DOI: 10.1053/j.jvca.2018.01.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Postoperative respiratory failure requiring reintubation is associated with a significant increase in mortality. However, perioperative risk factors and their effects on unplanned 30-day reintubation and postoperative outcomes after unplanned reintubation following lung resection are not described well. The aim of this study was to determine whether certain comorbidities, demographic factors, and postoperative outcomes are associated with 30-day reintubation after thoracic surgery. DESIGN This was a retrospective observational study using multivariable logistic regression to identify preoperative risk factors and consequences of unplanned 30-day reintubation. SETTING Multi-institutional, prospective, surgical outcome-oriented database study. PARTICIPANTS Using the American College of Surgeons National Surgical Quality Improvement Program database, video-assisted thorascopic surgery and thoracotomy lung resections (lobectomy, wedge resection, segmentectomy, bilobectomy, pneumonectomy) were analyzed by Common Procedural Terminology codes from the years 2007 to 2016 in 16,696 patients undergoing thoracic surgery. INTERVENTION None. MEASUREMENT AND MAIN RESULTS The final analysis included 16,696 patients, of who 593 (3.5%) underwent unplanned reintubation. Among the final study population, 137 (23%) of unplanned intubations occurred within 24 hours postoperatively and the median (25%, 75% quartile) day of reintubation was day 3 (2, 8 days). The final multivariable logistic regression analysis suggested that age, American Society of Anesthesiologists physical status classification score ≥4, dyspnea with moderate exertion and at rest, history of chronic obstructive pulmonary disease, male sex, smoking, functional dependence, steroid use, open thoracotomies, increased operation time, and preoperative laboratory results (albumin and hematocrit) were associated with unplanned intubation after lung resection (p < 0.05). Unplanned intubation was associated significantly with 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay (p < 0.05). CONCLUSIONS Nonmodifiable and modifiable preoperative risk factors were associated with increased odds of unplanned reintubation. Patients who experienced unplanned intubation were at considerable risk for 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay.
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Affiliation(s)
- Brittany N Burton
- Department of Anesthesiology, University of California, San Diego, San Diego, California
| | - Swapnil Khoche
- Department of Anesthesiology, University of California, San Diego, San Diego, California
| | - Alison M A'Court
- Department of Anesthesiology, University of California, San Diego, San Diego, California
| | - Ulrich H Schmidt
- Department of Anesthesiology, University of California, San Diego, San Diego, California
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, San Diego, California; Department of Biomedical Informatics, University of California, San Diego, San Diego, California.
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11
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Lieberman-Cribbin W, Galsky M, Casey M, Liu B, Oh W, Flores R, Taioli E. Hospital Centralization Impacts High-Risk Lung and Bladder Cancer Surgical Patients. Cancer Invest 2017; 35:652-661. [DOI: 10.1080/07357907.2017.1406495] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Wil Lieberman-Cribbin
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Matthew Galsky
- Division of Hematology and Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Martin Casey
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bian Liu
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William Oh
- Division of Hematology and Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raja Flores
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emanuela Taioli
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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12
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Lieberman-Cribbin W, Liu B, Leoncini E, Flores R, Taioli E. Temporal trends in centralization and racial disparities in utilization of high-volume hospitals for lung cancer surgery. Medicine (Baltimore) 2017; 96:e6573. [PMID: 28422849 PMCID: PMC5406065 DOI: 10.1097/md.0000000000006573] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Racial disparities have been suggested in hospital utilization and outcome for lung cancer surgery, but the effect of hospital centralization on closing this gap is unknown. We hypothesized that centralization has increased the utilization of high- or very-high-volume (HV/VHV) hospitals, a proxy for access to high-quality care, over the study period independently from race.Inpatient records were extracted from the New York Statewide Planning and Research Cooperative System database (1995-2012) according to Clinical Modification of the International Classification of Diseases, 9th Revision diagnosis codes 162.* and 165.* and surgical procedure codes 32.2-32.6 (n = 31,931). Patients treated exclusively with surgery of black or white race with a valid zip code were included. Logistic models were performed to determine factors associated with utilization of HV/VHV or low- or very-low-volume (LV/VLV) hospitals; these models were subsequently stratified by race.The percentage of both black and white patients utilizing HV/VHV hospitals increased over the study period (+22.7% and 13.9%, respectively). The distance to the nearest HV/VHV hospital and patient-hospital distance were significantly lower in black compared to white patients, however, blacks were consistently less likely to use HV/VHV than whites (odds ratioadj: 0.26; 95% confidence interval: 0.23-0.29), and were significantly more likely to utilize urban, teaching, and lower volume hospitals than whites. Likelihood of HV/VHV utilization decreased with an increasing distance from a HV/VHV hospital, overall and separately for black and white patients.Although centralization has increased the utilization of HV/VHV for both black and white patients, racial differences in access and utilization of HV hospitals persisted.
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Affiliation(s)
- Wil Lieberman-Cribbin
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Bian Liu
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Emanuele Leoncini
- Institute of Public Health, Section of Hygiene, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Raja Flores
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Emanuela Taioli
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY
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13
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Nellis JC, Tufano RP, Gourin CG. Association between Magnesium Disorders and Hypocalcemia following Thyroidectomy. Otolaryngol Head Neck Surg 2016; 155:402-10. [PMID: 27118818 DOI: 10.1177/0194599816644594] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/24/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To identify factors associated with postoperative hypocalcemia after thyroid surgery and to understand the relationship among hypocalcemia, length of hospitalization, and costs of care. STUDY DESIGN Retrospective database analysis. METHODS Discharge data from the Nationwide Inpatient Sample for 620,744 patients who underwent thyroid surgery from 2001 to 2010 were analyzed through cross-tabulations and multivariate regression modeling. Hypocalcemia, length of stay, and costs were examined as dependent variables. Secondary independent variables included magnesium and phosphate metabolism disorders, vitamin D deficiency, menopause, sex, extent of surgery, malignancy, and surgeon volume. RESULTS Hypocalcemia was reported in 6% of patients and was significantly more common for the following variables: women, age <65 years, patients from the Northeast, total thyroidectomy ± neck dissection patients, low-volume surgical care, malignancy, recurrent laryngeal nerve injury, and patients with disorders of magnesium or phosphate metabolism (P < .001). Magnesium and phosphate disorders were present in <1% of patients. Magnesium disorders were significantly more likely for patients with hypocalcemia (7%; P < .001), and hypocalcemia was present in 52% of patients with magnesium disorders (P < .001). On multiple logistic regression analysis, the odds of hypocalcemia were greatest for patients with magnesium disorders (odds ratio, 12.71; 95% confidence interval, 8.59-18.82). This relationship was not attenuated by high-volume surgical care. Hypocalcemia and magnesium disorders were both associated with increased length of stay and costs, with a greater effect for magnesium disorders than for hypocalcemia (P < .001). CONCLUSIONS Disorders of magnesium metabolism are an independent risk factor for postthyroidectomy hypocalcemia and are associated with significantly increased costs and length of stay.
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Affiliation(s)
- Jason C Nellis
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ralph P Tufano
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
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Patients Selected for Definitive Concurrent Chemoradiation at High-volume Facilities Achieve Improved Survival in Stage III Non-Small-Cell Lung Cancer. J Thorac Oncol 2016; 10:937-43. [PMID: 25738221 DOI: 10.1097/jto.0000000000000519] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The relationship between provider experience and clinical outcomes is poorly defined in radiation oncology. This study examined the impact of facility case volume on overall survival in patients with stage III non-small cell lung cancer (NSCLC) treated with definitive concurrent chemoradiation therapy (CCRT). METHODS Using the National Cancer Data Base, we identified clinical stage III NSCLC patients diagnosed in 2004 to 2006 who were treated with definitive CCRT to 59.4-74.0 Gy. High-volume facilities (HVF) were defined as those in the ninetieth percentile of annual CCRT volume (≥12 cases/year). Independent predictors of receiving CCRT at HVF were identified using multivariable logistic regression. Overall survival based on receiving CCRT at HVF was assessed using Kaplan-Meier analysis, Cox proportional hazards regression, and propensity score matching. RESULTS Among 10,072 included patients, 1207 (12.0%) were treated at HVF. Patients in HVF were more likely to have a higher Charlson-Deyo comorbidity score, more advanced nodal stage, higher doses, and 3D-conformal or intensity-modulated radiotherapy. When controlling for demographic and clinical covariates including academic affiliation, treatment at HVF was independently associated with a significantly decreased risk of death (hazards ratio = 0.93; 95% confidence interval: 0.87-0.99; p = 0.03). Propensity score matching showed that these findings were robust (hazards ratio = 0.91; 95% confidence interval: 0.84-0.99; p = 0.04). CONCLUSIONS Our findings suggest that treatment at HVF is associated with improved overall survival among stage III NSCLC patients receiving definitive CCRT, independent of academic affiliation. Further research is needed to determine whether or not efforts supporting centralization of radiotherapy at HVF will improve population-based survival, toxicities, and costs.
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15
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Sineshaw HM, Wu XC, Flanders WD, Osarogiagbon RU, Jemal A. Variations in Receipt of Curative-Intent Surgery for Early-Stage Non-Small Cell Lung Cancer (NSCLC) by State. J Thorac Oncol 2016; 11:880-9. [PMID: 26980472 DOI: 10.1016/j.jtho.2016.03.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 03/01/2016] [Accepted: 03/03/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Previous studies reported racial and socioeconomic disparities in receipt of curative-intent surgery for early-stage non-small cell lung cancer (NSCLC) in the United States. We examined variation in receipt of surgery and whether the racial disparity varies by state. METHODS Patients in whom stage I or II NSCLC was diagnosed from 2007 to 2011 were identified from 38 state and the District of Columbia population-based cancer registries compiled by the North American Association of Central Cancer Registries. Percentage of patients receiving curative-intent surgery was calculated for each registry. Adjusted risk ratios were generated by using modified Poisson regression to control for sociodemographic (e.g., age, sex, race, insurance) and clinical (e.g., grade, stage) factors. Non-Hispanic (NH) whites and Massachusetts were used as references for comparisons because they had the lowest uninsured rates. RESULTS In all registries combined, 66.4% of patients with early-stage NSCLC (73,475 of 110,711) received curative-intent surgery. Receipt of curative-intent surgery for early-stage NSCLC varied substantially by state, ranging from 52.2% to 56.1% in Wyoming, Louisiana, and New Mexico to 75.2% to 77.2% in Massachusetts, New Jersey, and Utah. In a multivariable analysis, the likelihood of receiving curative-intent surgery was significantly lower in all but nine states/registries compared with Massachusetts, ranging from 7% lower in California to 25% lower in Wyoming. Receipt of curative-intent surgery for early-stage NSCLC was lower for NH blacks than for NH whites in every state, although statistically significant in Florida and Texas. CONCLUSIONS Receipt of curative-intent surgery for early-stage NSCLC varies substantially across states in the United States, with northeastern states generally showing the highest rates. Further, receipt of treatment appeared to be lower in NH blacks than in NH whites in every state, although statistically significant in Florida and Texas.
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Affiliation(s)
| | - Xiao-Cheng Wu
- Louisiana Tumor Registry, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - W Dana Flanders
- American Cancer Society, Atlanta, Georgia; Rollins School of Public Health, Emory University, Atlanta, Georgia
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16
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Ruparel M, Navani N. Fulfilling the Dream. Toward Reducing Inequalities in Lung Cancer Screening. Am J Respir Crit Care Med 2015; 192:125-7. [PMID: 26177167 DOI: 10.1164/rccm.201505-0897ed] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Mamta Ruparel
- 1 Lungs for Living Research Centre University College London London, United Kingdom
| | - Neal Navani
- 1 Lungs for Living Research Centre University College London London, United Kingdom
- 2 Department of Thoracic Medicine University College London Hospital London, United Kingdom
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17
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Mulvey CL, Smith TJ, Gourin CG. Use of inpatient palliative care services in patients with metastatic incurable head and neck cancer. Head Neck 2015; 38:355-63. [PMID: 25331744 DOI: 10.1002/hed.23895] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Substantial health care resources are used on aggressive end-of-life care, despite an increasing recognition that palliative care improves quality of life and reduces health care costs. We examined the incidence of palliative care encounters in in-patients with incurable head and neck cancer and associations with in-hospital mortality, length of hospitalization, and costs. METHODS Data from the Nationwide Inpatient Sample (NIS) for 80,514 head and neck cancer patients with distant metastatic disease in 2001 to 2010 was analyzed using cross-tabulations and multivariate regressions. RESULTS Palliative care encounters occurred in 4029 cases (5%) and were significantly associated with age ≥80 years, female sex, self-pay payor status, and prior radiation. Palliative care was significantly associated with increased in-hospital mortality and reduced hospital-related costs. CONCLUSION Inpatient palliative care consultation in terminal head and neck cancer is associated with reduced hospital-related costs, but appears to be underutilized and restricted to the elderly, uninsured, and patients with an increased risk of mortality.
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Affiliation(s)
- Carolyn L Mulvey
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Thomas J Smith
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Christine G Gourin
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
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18
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Harrison MA, Hegarty SE, Keith SW, Cowan SW, Evans NR. Racial disparity in in-hospital mortality after lobectomy for lung cancer. Am J Surg 2015; 209:652-8. [DOI: 10.1016/j.amjsurg.2014.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 09/26/2014] [Accepted: 11/21/2014] [Indexed: 10/24/2022]
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Mulvey CL, Pronovost PJ, Gourin CG. Hospital volume and failure to rescue after head and neck cancer surgery. Otolaryngol Head Neck Surg 2015; 152:783-9. [PMID: 25681489 DOI: 10.1177/0194599815570026] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 01/08/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate the relationship between hospital volume and mortality, complications, and failure-to-rescue rates among patients undergoing head and neck cancer (HNCA) surgery. STUDY DESIGN Cross-sectional analysis. SETTING Nationwide Inpatient Sample. SUBJECTS AND METHODS Discharge data for 159,301 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm from 2001 to 2010 were analyzed using cross-tabulations and multivariate regression modeling. Failure to rescue was defined as death after a major complication, including acute myocardial infarction, acute renal failure, venous thromboembolism, pneumonia, gastrointestinal bleed, pulmonary failure, hemorrhage, or surgical site infection. We compared the incidence of mortality, major complications, and failure-to-rescue rates across hospital volume tertiles. RESULTS The majority of hospitals performing HNCA surgery were low-volume hospitals, which performed a mean of 6 HNCA cases per year (n = 7635). Intermediate-volume hospitals performed a mean of 37 cases per year (n = 729), and high-volume hospitals performed a mean of 131 cases (n = 207). High-volume hospital care was associated with significantly decreased odds of death (odds ratio, 0.56; 95% confidence interval, 0.46-0.86) and failure to rescue (odds ratio, 0.56; 95% confidence interval, 0.33-0.97) compared to low-volume hospital care. However, there was no significant difference in major complication rates between patients undergoing HNCA surgery at high-volume hospitals and those at low-volume hospitals. CONCLUSION Patients with HNCA who receive care at high-volume hospitals compared with low-volume hospitals have a 44% lower odds of mortality, which appears to be associated with differences in the response to and management of complications rather than differences in complication rates.
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Affiliation(s)
- Carolyn L Mulvey
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Peter J Pronovost
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland Department of Health Policy and Management, Bloomberg School of Public Health, Baltimore, Maryland
| | - Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland
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20
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Efird JT, Landrine H, Shiue KY, O'Neal WT, Podder T, Rosenman JG, Biswas T. Race, insurance type, and stage of presentation among lung cancer patients. SPRINGERPLUS 2014; 3:710. [PMID: 25674451 PMCID: PMC4320244 DOI: 10.1186/2193-1801-3-710] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 11/26/2014] [Indexed: 12/18/2022]
Abstract
The purpose of this study was to determine whether African-American lung cancer patients are diagnosed at a later stage than white patients, regardless of insurance type. The relationship between race and stage at diagnosis by insurance type was assessed using a Poisson regression model, with relative risk as the measure of association. The setting of the study was a large tertiary care cancer center located in the southeastern United States. Patients who were diagnosed with lung cancer between 2001 and 2010 were included in the study. A total of 717 (31%) African-American and 1,634 (69%) white lung cancer patients were treated at our facility during the study period. Adjusting for age, sex, and smoking-related histology, African-American patients were diagnosed at a statistically significant later stage (III/IV versus I/II) than whites for all insurance types, with the exception of Medicaid. Our results suggest that equivalent insurance coverage may not ensure equal presentation of stage between African-American and white lung cancer patients. Future research is needed to determine whether other factors such as treatment delays, suboptimal preventive care, inappropriate specialist referral, community segregation, and a lack of patient trust in health care providers may explain the continuing racial disparities observed in the current study.
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Affiliation(s)
- Jimmy T Efird
- Center for Health Disparities, Brody School of Medicine, East Carolina University, Greenville, NC 27834 USA ; Leo Jenkins Cancer Center, Brody School of Medicine, East Carolina University, Greenville, NC USA
| | - Hope Landrine
- Center for Health Disparities, Brody School of Medicine, East Carolina University, Greenville, NC 27834 USA
| | - Kristin Y Shiue
- Center for Health Disparities, Brody School of Medicine, East Carolina University, Greenville, NC 27834 USA
| | - Wesley T O'Neal
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC USA
| | - Tarun Podder
- Department of Radiation Oncology, Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH USA
| | - Julian G Rosenman
- Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Tithi Biswas
- Department of Radiation Oncology, Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH USA
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21
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Gourin CG, Couch ME, Johnson JT. Effect of weight loss on short-term outcomes and costs of care after head and neck cancer surgery. Ann Otol Rhinol Laryngol 2014; 123:101-10. [PMID: 24574465 DOI: 10.1177/0003489414523564] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Patients with head and neck cancer (HNC) frequently present with weight loss secondary to dysphagia and malnutrition. We sought to determine the relationship between weight loss and in-hospital mortality, complications, length of hospitalization, and costs in HNC surgery. METHODS We analyzed discharge data from the Nationwide Inpatient Sample for 93,663 patients who underwent an ablative procedure for malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasms between 2003 and 2008. RESULTS Weight loss was significantly associated with dysphagia (relative risk ratio [RRR] = 3.0; p < 0.001), alcohol abuse (RRR = 2.0; p < 0.001), advanced comorbidity (RRR = 1.8; p < 0.001), Medicaid payor status (RRR = 1.6; p = 0.002), urgent or emergent admission (RRR = 1.7; p = 0.015), and major surgical procedures (RRR = 2.3; p < 0.001). Patients with weight loss had increased risks of acute cardiac events, pneumonia, renal failure, sepsis, pulmonary failure (RRR = 2.6; p < 0.001), and postoperative wound healing complications, including fistula, dehiscence, and surgical site infection (RRR = 2.0; p < 0.001). After we controlled for all other variables, weight loss was associated with significantly increased length of hospitalization and hospital-related costs. CONCLUSIONS Weight loss is associated with increases in medical complications, surgical complications, length of hospitalization, and hospital-related costs in HNC surgical patients. Aggressive preoperative identification and treatment of underlying dysphagia and malnutrition may reduce the medical and surgical morbidity in this high-risk population.
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Affiliation(s)
- Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland (Gourin)
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22
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Bloo GJA, Hesselink GJ, Oron A, Emond EJJM, Damen J, Dekkers WJM, Westert G, Wolff AP, Calsbeek H, Wollersheim HC. Meta-analysis of operative mortality and complications in patients from minority ethnic groups. Br J Surg 2014; 101:1341-9. [PMID: 25093587 DOI: 10.1002/bjs.9609] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/25/2014] [Accepted: 06/09/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Insight into the effects of ethnic disparities on patients' perioperative safety is necessary for the development of tailored improvement strategies. The aim of this study was to review the literature on safety differences between patients from minority ethnic groups and those from the ethnic majority undergoing surgery. METHODS PubMed, CINAHL, the Cochrane Library and Embase were searched using predefined inclusion criteria for available studies from January 1990 to January 2013. After quality assessment, the study data were organized on the basis of outcome, statistical significance and the direction of the observed effects. Relative risks for mortality were calculated. RESULTS After screening 3105 studies, 26 studies were identified. Nine of these 26 studies showed statistically significant higher mortality rates for patients from minority ethnic groups. Meta-analysis demonstrated a greater risk of mortality for these patients compared with patients from the Caucasian majority in studies performed both in North America (risk ratio 1·22, 95 per cent confidence interval 1·05 to 1·42) and outside (risk ratio 2·25, 1·40 to 3·62). For patients from minority groups, the length of hospital or intensive care unit stay was significantly longer in five studies, and complication rates were significantly higher in ten. Methods used to identify patient ethnicity were not described in 14 studies. CONCLUSION Patients from minority ethnic groups, in North America and elsewhere, have an increased risk of perioperative death and complications. More insight is needed into the causes of ethnic disparities to pursue safer perioperative care for patients of minority ethnicity.
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Affiliation(s)
- G J A Bloo
- Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands; Department of Anaesthesiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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23
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Gooi Z, Gourin CG, Boahene KDO, Byrne PJ, Richmon JD. Temporal trends in head and neck cancer surgery reconstruction. Head Neck 2014; 37:1509-17. [DOI: 10.1002/hed.23786] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 03/14/2014] [Accepted: 05/28/2014] [Indexed: 11/09/2022] Open
Affiliation(s)
- Zhen Gooi
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins University; Baltimore Maryland
| | - Christine G. Gourin
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins University; Baltimore Maryland
- Armstrong Institute for Patient Safety and Quality; Johns Hopkins University; Baltimore Maryland
| | - Kofi D. O. Boahene
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins University; Baltimore Maryland
| | - Patrick J. Byrne
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins University; Baltimore Maryland
| | - Jeremy D. Richmon
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins University; Baltimore Maryland
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24
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Genther DJ, Gourin CG. Effect of comorbidity on short-term outcomes and cost of care after head and neck cancer surgery in the elderly. Head Neck 2014; 37:685-93. [PMID: 24596299 DOI: 10.1002/hed.23651] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 02/18/2014] [Accepted: 03/01/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND With increased life expectancy, there is growing awareness of the effect of comorbidity on physiologic reserves in elderly patients. Data in the area of head and neck cancer surgery is lacking. METHODS Retrospective data from 61,740 elderly patients who underwent a head and neck cancer ablative surgery from 2001 to 2010 using the Nationwide Inpatient Sample were analyzed to examine associations between comorbidity and in-hospital mortality, postoperative complications, length of hospitalization, and hospital-related costs. RESULTS Advanced comorbidity was present in 18% of elderly patients, who were more likely to experience acute medical complications (odds ratio [OR], 3.7; p < .001), in-hospital death (OR, 3.6; p < .001), increased length of hospitalization (mean, 2.2 days; p < .001), and hospital-related costs (mean, $6874; p < .001). CONCLUSION Advanced comorbidity in elderly surgical patients with head and neck cancer is associated with increased mortality, morbidity, length of hospitalization, and hospital-related costs. This increased utilization of health care resources may pose challenges to health care reform efforts as the population ages.
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Affiliation(s)
- Dane J Genther
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
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25
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Kronebusch K, Gray BH, Schlesinger M. Explaining racial/ethnic disparities in use of high-volume hospitals: decision-making complexity and local hospital environments. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2014; 51:51/0/0046958014545575. [PMID: 25316717 PMCID: PMC5813660 DOI: 10.1177/0046958014545575] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Racial/ethnic minorities are less likely to use higher-quality hospitals than whites. We propose that a higher level of information-related complexity in their local hospital environments compounds the effects of discrimination and more limited access to services, contributing to racial/ethnic disparities in hospital use. While minorities live closer than whites to high-volume hospitals, minorities also face greater choice complexity and live in neighborhoods with lower levels of medical experience. Our empirical results reveal that it is generally the overall context associated with proximity, choice complexity, and local experience, rather than differential sensitivity to these factors, that provides a partial explanation of the disparity gap in high-volume hospital use.
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Ganti AK, Subbiah SP, Kessinger A, Gonsalves WI, Silberstein PT, Loberiza FR. Association between race and survival of patients with non--small-cell lung cancer in the United States veterans affairs population. Clin Lung Cancer 2013; 15:152-8. [PMID: 24361249 DOI: 10.1016/j.cllc.2013.11.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 11/08/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Racial disparities in outcomes of non-small-cell lung cancer (NSCLC) patients in the United States are well documented. A retrospective analysis of patients in the Veterans Affairs Central Cancer Registry was conducted to determine whether similar disparities exist in a population with a single-payer, accessible health care system. PATIENTS AND METHODS Demographic data of patients diagnosed with NSCLC between January 1995 and February 2009 were analyzed using Kruskal-Wallis test or the χ(2) test. Multivariate Cox proportional hazards regression analysis was used to compare survival among races. RESULTS Of the 82,414 patients, 98% were male, 82% had a smoking history, and 81% were Caucasian. Caucasian individuals had better prognostic features compared with African-American individuals (stage I/II [24% vs. 21%]; Grade I/II [21% vs. 17%]). A larger proportion of Caucasian compared with African-American individuals received stage-appropriate treatment (surgery for stage I [48% vs. 41%; P < .001]; chemotherapy for stage IV [18% vs. 16%; P = .003]). African-American individuals had a lower risk of mortality compared with Caucasian individuals (hazard ratio, 0.94; 95% confidence interval, 0.92-0.96). CONCLUSION Although African-American patients had a higher stage and grade of NSCLC, they had a better overall survival than Caucasian patients. In a single-payer system with accessible health care, previously described racial differences in lung cancer outcomes were not observed.
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Affiliation(s)
- Apar Kishor Ganti
- Department of Internal Medicine, VA Nebraska Western Iowa Health Care System, Omaha, NE; Division of Oncology/Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE.
| | - Shanmuga P Subbiah
- Department of Internal Medicine, VA Nebraska Western Iowa Health Care System, Omaha, NE; Division of Oncology/Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Division of Oncology/Hematology, Department of Internal Medicine, Creighton University Medical Center, Omaha, NE
| | - Anne Kessinger
- Division of Oncology/Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Wilson I Gonsalves
- Division of Oncology/Hematology, Department of Internal Medicine, Creighton University Medical Center, Omaha, NE
| | - Peter T Silberstein
- Department of Internal Medicine, VA Nebraska Western Iowa Health Care System, Omaha, NE; Division of Oncology/Hematology, Department of Internal Medicine, Creighton University Medical Center, Omaha, NE
| | - Fausto R Loberiza
- Division of Oncology/Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
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27
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Richmon JD, Quon H, Gourin CG. The effect of transoral robotic surgery on short‐term outcomes and cost of care after oropharyngeal cancer surgery. Laryngoscope 2013; 124:165-71. [DOI: 10.1002/lary.24358] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/07/2013] [Accepted: 07/22/2013] [Indexed: 11/06/2022]
Affiliation(s)
- Jeremy D. Richmon
- Department of Otolaryngology–Head and Neck SurgeryJohns Hopkins Medical InstitutionsBaltimore Maryland U.S.A
| | - Harry Quon
- Department of Otolaryngology–Head and Neck SurgeryJohns Hopkins Medical InstitutionsBaltimore Maryland U.S.A
- Department of Radiation Oncology and Molecular Radiation SciencesJohns Hopkins Medical InstitutionsBaltimore Maryland U.S.A
| | - Christine G. Gourin
- Department of Otolaryngology–Head and Neck SurgeryJohns Hopkins Medical InstitutionsBaltimore Maryland U.S.A
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Howington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e278S-e313S. [PMID: 23649443 DOI: 10.1378/chest.12-2359] [Citation(s) in RCA: 913] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined. METHODS The writing panel selected topics for review based on clinical relevance to treatment of early-stage lung cancer and the amount and quality of data available for analysis and relative controversy on best approaches in stage I and II NSCLC: general surgical care vs specialist care; sublobar vs lobar surgical approaches to stage I lung cancer; video-assisted thoracic surgery vs open resection; mediastinal lymph node sampling vs lymphadenectomy at the time of surgical resection; the use of radiation therapy, with a focus on SBRT, for primary treatment of early-stage NSCLC in high-risk or medically inoperable patients as well as adjuvant radiation therapy in the sublobar and lobar resection settings; adjuvant chemotherapy for early-stage NSCLC; and the impact of ethnicity, geography, and socioeconomic status on lung cancer survival. Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians. RESULTS Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. The use of sublobar resection for T1a tumors and the application of adjuvant radiation therapy in this group are being actively studied in large clinical trials. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. Primary radiation therapy remains the primary curative intent approach for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving. Radiofrequency ablation, the most studied of the ablative modalities, has been used effectively in medically inoperable patients with small (< 3 cm) peripheral NSCLC that are clinical stage I.
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Affiliation(s)
- John A Howington
- NorthShore HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, IL.
| | - Matthew G Blum
- Penrose Cardiothoracic Surgery, Memorial Hospital, University of Colorado Health, Colorado Springs, CO
| | | | - Alex A Balekian
- Division of Pulmonary, Critical Care, and Sleep Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Sudish C Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
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Johnston WF, LaPar DJ, Newhook TE, Stone ML, Upchurch GR, Ailawadi G. Association of race and socioeconomic status with the use of endovascular repair to treat thoracic aortic diseases. J Vasc Surg 2013; 58:1476-82. [PMID: 23911247 DOI: 10.1016/j.jvs.2013.05.095] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 05/20/2013] [Accepted: 05/21/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Descending thoracic aortic diseases may be treated with either open thoracic aortic repair or thoracic endovascular aortic repair (TEVAR). Previous studies have demonstrated that race and socioeconomic status (SES) affect access to care and treatment allocation in vascular surgery. We hypothesized that racial minorities and lower SES patients have decreased propensity to have their thoracic aortic disease treated with TEVAR. METHODS Weighted discharge records for patients who underwent either open thoracic aortic repair or TEVAR between 2005 and 2008 were evaluated using the Nationwide Inpatient Sample. Patient records were stratified by therapeutic intervention (open repair vs TEVAR). Differences in baseline comorbidities, race, and SES were compared. To account for the effects of comorbidities and other factors, hierarchical logistic regression modeling was used to determine the likelihood for TEVAR performance based on differences in patients' race and SES. RESULTS A total of 60,784 thoracic repairs were analyzed, the majority (79.4%) of which were open repairs. The most common race was white (78.2%), followed by black (9.1%), Hispanic (5.7%), Asian or Pacific Islander (2.9%), and Native American (0.7%). Patients were divided into quartiles according to SES with 20.6% of patients in the lowest SES quartile, 24.3% in the second quartile, 26.4% in the third quartile, and 28.8% in the highest SES quartile. Indications for treatment were similar for both treatment groups. After adjusting for multiple patient and hospital factors, race and SES were significantly associated with treatment modality for thoracic aortic disease. Black, Hispanic, and Native American populations had increased adjusted odds ratios of TEVAR performance compared with white patients. Similarly, lower SES correlated with increased use of TEVAR. CONCLUSIONS Contrary to our initial hypothesis, racial minorities (Black, Hispanic, and Native American) and patients with lower median household incomes have a greater association with the performance for TEVAR after accounting for patient comorbid disease, indication for treatment, payer status, and hospital volume. These results indicate that traditional racial disparities do not persist in TEVAR allocation.
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State-by-state variation in emergency versus elective colon resections: room for improvement. J Trauma Acute Care Surg 2013; 74:1286-91. [PMID: 23609280 DOI: 10.1097/ta.0b013e31828b8478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Compared with elective surgical procedures, emergency procedures are associated with higher cost, morbidity, and mortality. This study seeks to investigate potential state-by-state variations in the incidence of emergent versus elective colon resections. METHODS A retrospective analysis of all adult patients (aged ≥18 years) included in the Nationwide Inpatient Sample from 2005 to 2009 who underwent hemicolectomy (right or left) or sigmoidectomy was conducted. Discharge-level weights were applied, and generalized linear models were used to assess the odds of a patient undergoing emergent versus elective colon surgery nationally and for each state after adjusting for patient and hospital factors. Odds ratios (ORs) were estimated with the national average as the reference. RESULTS The final study cohort included 203,050 observations composed of 83,090 emergent and 119,960 elective colectomies. The state with the highest unadjusted proportion of emergent procedures was Nevada (53.6%), whereas Texas had the lowest (22.8%) [corrected]. Compared with the national average, the adjusted odds of undergoing emergency colectomy remained highest in Nevada (OR, 1.70; 95% confidence interval, 1.54-1.87) and lowest in Texas (OR, 0.43; 95% confidence interval, 0.36-0.51). CONCLUSION Substantial state variations exist in rates of emergency colon surgery within the United States. Identification of these differences suggests significant variations in practice and a potential to decrease the number of emergent colon operations.
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Hennessey PT, Francis HW, Gourin CG. Is there a "July effect" for head and neck cancer surgery? Laryngoscope 2013; 123:1889-95. [PMID: 23737378 DOI: 10.1002/lary.23884] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2012] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS A "July effect" of increased complications when new trainees begin residency has been reported widely by the media. We sought to determine the effect of admission month on in-hospital mortality, complications, length of hospitalization, and costs for patients undergoing head and neck cancer (HNCA) surgery. STUDY DESIGN Retrospective cross-sectional study. METHODS Discharge data from the Nationwide Inpatient Sample for 48,263 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm in 2005 to 2008 were analyzed using cross-tabulations and multivariate regression modeling. RESULTS There were 3,812 cases admitted in July (8%). July admission was significantly associated with Medicaid (RRR 1.40, P = 0.011) or self-pay payor status (RRR 1.40, P = 0.022), medium hospital bed size (RRR 1.63, P = 0.033) and large hospital bed size (RRR 1.73, P = 0.013). There was no association between July admission and other patient or hospital demographic characteristics. Major procedures and comorbidity were significantly associated with in-hospital death, surgical and medical complications, length of hospitalization, and costs, but no association was found for July admission, July through September discharge, or teaching hospital status and short-term morbidity or mortality. Teaching hospitals and large hospital bed size were predictors of increased length of hospitalization and costs; and private, for profit hospitals were additionally associated with increased costs. No interaction between July admission and teaching hospitals was found for any of the outcome variables studied. CONCLUSIONS These data do not support evidence of a "July effect" or an increase in morbidity or mortality at teaching hospitals providing HNCA surgical care.
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Affiliation(s)
- Patrick T Hennessey
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland 21287, USA
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Chan JYK, Li RJ, Gourin CG. Short-term outcomes and cost of care of treatment of head and neck paragangliomas. Laryngoscope 2013; 123:1645-51. [DOI: 10.1002/lary.23856] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Revised: 08/21/2012] [Accepted: 10/08/2012] [Indexed: 11/09/2022]
Affiliation(s)
- Jason Y. K. Chan
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins University; Baltimore; Maryland; U.S.A
| | - Ryan J. Li
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins University; Baltimore; Maryland; U.S.A
| | - Christine G. Gourin
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins University; Baltimore; Maryland; U.S.A
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Loyo M, Tufano RP, Gourin CG. National trends in thyroid surgery and the effect of volume on short-term outcomes. Laryngoscope 2013; 123:2056-63. [DOI: 10.1002/lary.23923] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 10/08/2012] [Accepted: 11/08/2012] [Indexed: 11/06/2022]
Affiliation(s)
- Myriam Loyo
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins University; Baltimore; Maryland; U.S.A
| | - Ralph P. Tufano
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins University; Baltimore; Maryland; U.S.A
| | - Christine G. Gourin
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins University; Baltimore; Maryland; U.S.A
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Kochhar A, Pronovost PJ, Gourin CG. Hospital-acquired conditions in head and neck cancer surgery. Laryngoscope 2013; 123:1660-9. [PMID: 23733563 DOI: 10.1002/lary.23975] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Revised: 11/20/2012] [Accepted: 12/14/2012] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS The Centers for Medicare and Medicaid Services has identified 10 hospital-acquired conditions (HACs) for which they will not reimburse care. We sought to determine the incidence of HACs in head and neck cancer (HNCA) surgery and the association with in-hospital mortality, complications, length of hospitalization, and costs. STUDY DESIGN Retrospective cross-sectional study. METHODS Discharge data from the Nationwide Inpatient Sample for 123,662 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm during 2001-2008 were analyzed using cross-tabulations and multivariate regression modeling. RESULTS HACs occurred in <1% of cases, with vascular catheter-associated infection comprising >70% of all HACs. The occurrence of HACs was significantly associated with urgent or emergent admission (odds ratio [OR]=2.0, P=.004), major surgical procedures (OR=2.3, P<.001), flap reconstruction (OR=3.5, P<.001), and advanced comorbidity (OR=2.0, P<.001). There was no association between HACs and hospital size, location, ownership, volume status, or safety-net burden. HACs were significantly associated with in-hospital mortality (OR=3.8, P=.001), surgical complications (OR=4.9, P<.001), and medical complications (OR=5.6, P<.001). After controlling for all other variables, HACs were associated with significantly increased length of hospitalization and hospital-related costs, with vascular catheter-associated infection and foreign object after surgery associated with the greatest increase in length of stay and costs. CONCLUSIONS HACs are uncommon events in HNCA surgical patients. Because prediction of HACs is poor and the potential for human error crosses demographic, geographic, and structural boundaries, universal innovative measures to reduce the occurrence of HACs are needed.
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Affiliation(s)
- Amit Kochhar
- Department of Otolaryngology-Head and Neck Surgery, Baltimore, Maryland, USA
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Li R, Fakhry C, Koch WM, Gourin CG. The Effect of tumor subsite on short-term outcomes and costs of care after oral cancer surgery. Laryngoscope 2013; 123:1652-9. [PMID: 23686386 DOI: 10.1002/lary.23952] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Revised: 11/29/2012] [Accepted: 11/29/2012] [Indexed: 12/20/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine if epidemiologic differences exist between patients with oral tongue carcinoma compared to tumors arising from other oral cavity subsites, and the relationship between primary site and in-hospital mortality, postoperative complications, length of stay, and costs in patients undergoing surgery for oral cavity cancer. STUDY DESIGN Retrospective cross-sectional study. METHODS The Nationwide Inpatient Sample was analyzed for patients who underwent an ablative procedure for a malignant oral cavity neoplasm in 2001 to 2008 using cross-tabulations and multivariate regression modeling. RESULTS Overall, there were 45,071 patients treated surgically for oral cavity cancer, with oral tongue cancer comprising 35% of all oral cavity tumors. Patients with oral tongue cancer were significantly more likely to be female (odds ratio [OR] = 1.4) and undergo neck dissection (OR = 1.4), and significantly less likely to be black (OR = 0.4), over 40 years of age (OR = 0.4), have Medicaid payer status (OR = 0.7), advanced comorbidity (OR = 0.7), receive care at a teaching hospital (OR = 0.5), and undergo pedicled or free flap reconstruction (OR = 0.6, P < .001). Oral tongue primary site was not associated with in-hospital mortality or surgical complications, but was significantly associated with a reduced incidence of medical complications (OR = 0.8, P = .005). After controlling for all other variables, oral tongue primary site disease was associated with a significantly reduced length of hospitalization and hospital-related costs. CONCLUSIONS Oral tongue cancer is associated with a distinct epidemiologic profile compared to other oral cavity cancer subsites, and is associated with lower postoperative morbidity, length of hospitalization, and hospital-related costs. Further investigation is warranted to determine if biologic factors underlie these observations.
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Affiliation(s)
- Ryan Li
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
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State-by-state variation in emergency versus elective colon resections: Room for improvement. J Trauma Acute Care Surg 2013. [DOI: 10.1097/01586154-201305000-00015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Groth SS, Al-Refaie WB, Zhong W, Vickers SM, Maddaus MA, D'Cunha J, Habermann EB. Effect of insurance status on the surgical treatment of early-stage non-small cell lung cancer. Ann Thorac Surg 2013; 95:1221-6. [PMID: 23415239 DOI: 10.1016/j.athoracsur.2012.10.079] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Revised: 10/29/2012] [Accepted: 10/31/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Social disparities permeate non-small cell lung cancer (NSCLC) treatment, yet little is known about the effect of insurance status on the delivery of guideline surgical treatment for early-stage (I or II) NSCLC. METHODS We used the California Cancer Registry (1996 through 2008) to identify patients 50 to 94 years old with early-stage NSCLC. We used logistic regression models to assess whether or not insurance status (private insurance, Medicare, Medicaid, no insurance, and unknown) had an effect on whether or not a lobectomy (or bilobectomy) is performed. RESULTS A total of 10,854 patients met our inclusion criteria. Compared with patients with private insurance, we found that patients with Medicare (adjusted odds ratio [aOR] 0.87; 95% confidence interval [CI]: 0.79 to 0.95), Medicaid (aOR 0.45; 95% CI: 0.36 to 0.57), or no insurance (aOR 0.45; 95% CI: 0.29 to 0.70) were significantly less likely to undergo lobectomy, even after adjusting for patient factors (age, race, and gender) and tumor characteristics (histology and tumor size). Increasing age, African American race, squamous cell carcinoma, and increasing tumor size were significant independent negative predictors of whether or not a lobectomy was performed. CONCLUSIONS Patients without private insurance were significantly less likely than patients with private insurance to undergo a lobectomy for early-stage NSCLC. The variables(s) contributing to this disparity have yet to be elucidated.
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Affiliation(s)
- Shawn S Groth
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Chan JYK, Semenov YR, Gourin CG. Postoperative Urinary Tract Infection and Short-Term Outcomes and Costs in Head and Neck Cancer Surgery. Otolaryngol Head Neck Surg 2013; 148:602-10. [DOI: 10.1177/0194599812474595] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Catheter-associated urinary tract infections (UTIs) have been identified as a preventable “never event” by the Centers for Medicare & Medicaid Services. We sought to determine the relationship between UTI and in-hospital mortality, postoperative complications, length of stay, and costs in head and neck cancer (HNCA) surgery. Study Design Cross-sectional analysis using cross-tabulations and multivariate regression modeling. Setting The Nationwide Inpatient Sample database. Subjects and Methods Discharge data for 93,663 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm in 2003-2008 were analyzed. Results Urinary tract infection was diagnosed in 2% of patients, with catheter-associated UTI coded in only 20 patients. Patients with UTI were more likely to be older than 80 years (odds ratio [OR], 3.3; P = .008), be female (OR, 1.9; P < .001), have advanced comorbidity (OR, 1.8; P < .012), undergo major surgical procedures (OR, 1.7; P = .001), and have predisposing bladder and prostate conditions (OR, 3.8; P < .001), surgical complications (OR, 2.3; P < .001), and acute medical complications (OR, 3.1; P < .001). Urinary tract infection was associated with significantly increased length of hospitalization and hospital-related costs, after controlling for all other variables. Conclusion Urinary tract infection is unusual in HNCA surgical patients but is more common with extent of surgery and age and is significantly associated with postoperative complications, length of hospitalization, and hospital-related costs. Catheter-associated UTI is likely underestimated because of difficulty in distinguishing between a catheter-associated UTI and postoperative UTI in patients undergoing major surgical procedures, who routinely undergo perioperative urinary catheterization. Patients with HNCA are a high-risk group for this “never event,” particularly as the population ages.
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Affiliation(s)
- Jason Y. K. Chan
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Yevgeniy R. Semenov
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christine G. Gourin
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
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Haider AH, Scott VK, Rehman KA, Velopulos C, Bentley JM, Cornwell EE, Al-Refaie W. Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors. J Am Coll Surg 2013; 216:482-92.e12. [PMID: 23318117 DOI: 10.1016/j.jamcollsurg.2012.11.014] [Citation(s) in RCA: 412] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Revised: 11/28/2012] [Accepted: 11/28/2012] [Indexed: 02/06/2023]
Affiliation(s)
- Adil H Haider
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Hennessey P, Semenov YR, Gourin CG. The effect of deep venous thrombosis on short-term outcomes and cost of care after head and neck cancer surgery. Laryngoscope 2012; 122:2199-204. [PMID: 22865644 DOI: 10.1002/lary.23459] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Revised: 04/30/2012] [Accepted: 05/03/2012] [Indexed: 11/12/2022]
Abstract
OBJECTIVES/HYPOTHESIS The Centers for Medicare and Medicaid Services has targeted deep venous thrombosis (DVT) and pulmonary embolus (PE) as preventable "never events" and has discontinued reimbursement for these conditions following selected orthopedic procedures. We sought to determine the relationship between DVT/PE and in-hospital mortality, postoperative complications, length of stay, and costs in head and neck cancer (HNCA) surgery. STUDY DESIGN Retrospective cross-sectional study. METHODS Discharge data from the Nationwide Inpatient Sample for 93,663 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm in 2003 to 2008 were analyzed using cross-tabulations and multivariate regression modeling. RESULTS DVT/PE was diagnosed in 1,860 cases (2%) and was significantly associated with major surgical procedures (odds ratio [OR], 1.4; P = .048) and advanced comorbidity (OR, 1.7; P = .034). After controlling for all other variables, no association was found between a diagnosis of DVT/PE and obesity, weight loss, age, chronic cardiac disease, paralysis, and smoking in this HNCA surgical population. DVT/PE was associated with increased risk of in-hospital mortality (OR, 3.1; P = .001), postoperative surgical complications (OR, 2.1; P < .001), acute medical complications (OR, 1.9; P < .001), and was associated with significantly increased length of hospitalization and hospital-related costs. CONCLUSIONS DVT/PE is uncommon in HNCA patients but is associated with increased mortality, postoperative complications, length of hospitalization, and hospital-related costs. The lack of correlation with known modifiable variables suggests that despite advances in targeted prophylaxis, patients with advanced disease and comorbidity remain at increased risk. Caution must be used in the institution of reforms that threaten to inadequately reimburse the provision of care in vulnerable populations.
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Affiliation(s)
- Patrick Hennessey
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland 21287, USA
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Semenov YR, Starmer HM, Gourin CG. The effect of pneumonia on short-term outcomes and cost of care after head and neck cancer surgery. Laryngoscope 2012; 122:1994-2004. [PMID: 22777881 DOI: 10.1002/lary.23446] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 04/15/2012] [Accepted: 04/26/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services has threatened to discontinue reimbursements for ventilator-associated pneumonia (VAP) as a preventable "never event." We sought to determine the relationship between pneumonia and in-hospital mortality, complications, length of hospitalization and costs in head and neck cancer (HNCA) surgery. STUDY DESIGN Retrospective cross-sectional study. METHODS Discharge data from the Nationwide Inpatient Sample for 93,663 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm from 2003 to 2008 were analyzed using cross-tabulations and multivariate regression modeling. RESULTS VAP was rarely coded. Infectious pneumonia was significantly associated with chronic pulmonary disease (odds ratio [OR], 1.5; P < .001), while aspiration pneumonia was associated with dysphagia (OR, 2.0; P < .001). Pneumonia from any cause was associated with weight loss (OR, 3.3; P < .001), age >80 years (OR, 2.0; P = .007), comorbidity (OR, 2.3; P < .001), and major procedures (OR, 1.6; P < .001), with increased in-hospital mortality for infectious (OR, 2.9; P < .001) and aspiration pneumonia (OR, 5.3; P < .001). Both infectious and aspiration pneumonia were associated with postoperative medical and surgical complications, increased length of hospitalization, and hospital-related costs. CONCLUSIONS Postoperative pneumonia is associated with increased mortality, complications, length of hospitalization, and hospital-related costs in HNCA surgical patients. Variables associated with an increased risk of pneumonia are inherent comorbidities in HNCA and known risk factors for VAP, making this a high-risk group for this never event. Caution must be used in the institution of reforms that threaten to inadequately reimburse the provision of care to this vulnerable population. Aggressive preoperative identification and treatment of underlying pulmonary disease, weight loss, and dysphagia may reduce morbidity and mortality.
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Affiliation(s)
- Yevgeniy R Semenov
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
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Esnaola NF, Ford ME. Racial differences and disparities in cancer care and outcomes: where's the rub? Surg Oncol Clin N Am 2012; 21:417-37, viii. [PMID: 22583991 PMCID: PMC4180671 DOI: 10.1016/j.soc.2012.03.012] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Despite a profusion of studies over the past several years documenting racial differences in cancer outcomes, there is a paucity of data as to the root causes underlying these observations. This article reviews work to date focusing on black-white differences in cancer outcomes, explores potential mechanisms underlying these differences, and identifies patient, physician, and health care system factors that may account for persistent racial disparities in cancer care. Research strategies to elucidate the relative influence of these various factors and policy recommendations to reduce persistent disparities are also discussed.
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Affiliation(s)
- Nestor F Esnaola
- Division of Surgical Oncology, Department of Surgery, Medical University of South Carolina, 25 Courtenay Drive, Suite 7018, Charleston, SC 29425, USA.
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Genther DJ, Gourin CG. The effect of alcohol abuse and alcohol withdrawal on short-term outcomes and cost of care after head and neck cancer surgery. Laryngoscope 2012; 122:1739-47. [DOI: 10.1002/lary.23348] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 02/26/2012] [Accepted: 03/19/2012] [Indexed: 11/08/2022]
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Case BG, Bertollo DN, Laska EM, Siegel CE, Wanderling JA, Olfson M. Racial differences in the availability and use of electroconvulsive therapy for recurrent major depression. J Affect Disord 2012; 136:359-65. [PMID: 22169249 PMCID: PMC3442372 DOI: 10.1016/j.jad.2011.11.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 11/01/2011] [Accepted: 11/14/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND Black Americans with depression were less likely to receive electroconvulsive therapy (ECT) than whites during the 1970s and 80s. This pattern was commonly attributed to treatment of blacks in lower quality hospitals where ECT was unavailable. We investigated whether a racial difference in receiving ECT persists, and, if so, whether it arises from lesser ECT availability or from lesser ECT use within hospitals conducting the procedure. METHODS Black or white inpatient stays for recurrent major depression from 1993 to 2007 (N=419,686) were drawn from an annual sample of US community hospital discharges. The marginal disparity ratio estimated adjusted racial differences in the probabilities of (1) admission to a hospital capable of conducting ECT (availability), and (2) ECT utilization if treated where ECT is conducted (use). RESULTS Across all hospitals, the probability of receiving ECT for depressed white inpatients (7.0%) greatly exceeded that for blacks (2.0%). Probability of ECT availability was slightly greater for whites than blacks (62.0% versus 57.8%), while probability of use was markedly greater (11.8% versus 3.9%). The white versus black marginal disparity ratio for ECT availability was 1.07 (95% confidence interval 1.06-1.07) and stable over the period, while the ratio for use fell from 3.2 (3.1-3.4) to 2.5 (2.4-2.7). LIMITATIONS Depressed persons treated in outpatient settings or receive no care are excluded from analyses. CONCLUSIONS Depressed black inpatients continue to be far less likely than whites to receive ECT. The difference arises almost entirely from lesser use of ECT within hospitals where it is available.
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Affiliation(s)
- Brady G Case
- Health Services Research Program, Emma Pendleton Bradley Hospital, East Providence, RI 02915, United States.
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Gourin CG, Frick KD. National trends in oropharyngeal cancer surgery and the effect of surgeon and hospital volume on short-term outcomes and cost of care. Laryngoscope 2012; 122:543-51. [DOI: 10.1002/lary.22447] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 02/18/2011] [Accepted: 02/23/2011] [Indexed: 02/06/2023]
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Gourin CG, Frick KD. National trends in laryngeal cancer surgery and the effect of surgeon and hospital volume on short-term outcomes and cost of care. Laryngoscope 2011; 122:88-94. [DOI: 10.1002/lary.22409] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 09/09/2011] [Accepted: 09/16/2011] [Indexed: 11/06/2022]
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Virgo KS, Little AG, Fedewa SA, Chen AY, Flanders WD, Ward EM. Safety-Net Burden Hospitals and Likelihood of Curative-Intent Surgery for Non-Small Cell Lung Cancer. J Am Coll Surg 2011; 213:633-43. [DOI: 10.1016/j.jamcollsurg.2011.07.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 07/18/2011] [Accepted: 07/18/2011] [Indexed: 10/17/2022]
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Pollack CE, Bekelman JE, Epstein AJ, Liao K, Wong YN, Armstrong K. Racial disparities in changing to a high-volume urologist among men with localized prostate cancer. Med Care 2011; 49:999-1006. [PMID: 22005606 PMCID: PMC3298812 DOI: 10.1097/mlr.0b013e3182364019] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patients who receive surgery from high-volume surgeons tend to have better outcomes. Black patients, however, are less likely to receive surgery from high-volume surgeons. OBJECTIVE Among men with localized prostate cancer, we examined whether disparities in use of high-volume urologists resulted from racial differences in patients being diagnosed by high-volume urologists and/or changing to high-volume urologists for surgery. RESEARCH DESIGN Retrospective cohort study from Surveillance, Epidemiology, and End Results-Medicare data. SUBJECTS A total of 26,058 black and white men in Surveillance, Epidemiology, and End Results-Medicare diagnosed with localized prostate cancer from 1995 to 2005 that underwent prostatectomy. Patients were linked to their diagnosing urologist and a treating urologist (who performed the surgery). MEASURES Diagnosis and receipt of prostatectomy by a high-volume urologist, and changing between diagnosing and treating urologist RESULTS After adjustment for confounders, black men were as likely as white men to be diagnosed by a high-volume urologist; however, they were significantly less likely than white men to be treated by a high-volume urologist [odds ratio 0.76; 95% confidence interval (CI), 0.67-0.87]. For men diagnosed by a low-volume urologist, 46.0% changed urologists for their surgery. Black men were significantly less likely to change to a high-volume urologist (relative risk ratio 0.61; 95% CI, 0.47-0.79). Racial differences appeared to reflect black and white patients being diagnosed by different urologists and having different rates of changing after being diagnosed by the same urologists. CONCLUSIONS Lower rates of changing to high-volume urologists for surgery among black men contribute to racial disparities in treatment by high-volume surgeons.
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Affiliation(s)
- Craig Evan Pollack
- Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, MD 21287, USA.
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McCabe CT, Woodruff SI, Zúñiga ML. Sociodemographic and substance use correlates of tobacco use in a large, multi-ethnic sample of emergency department patients. Addict Behav 2011; 36:899-905. [PMID: 21561718 DOI: 10.1016/j.addbeh.2011.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 02/09/2011] [Accepted: 04/13/2011] [Indexed: 11/24/2022]
Abstract
Strong evidence suggests marked disparities among ethnic minorities in relation to tobacco use. To date, a majority of the data available discusses tobacco use in the general population. Using a sample of Latino, non-Latino Black (NLB), and non-Latino White (NLW) patients presenting to the emergency departments, the present study examined sociodemographic and substance use correlates of past 3-month tobacco use. Over 48,000 patients were interviewed as part of a screening and brief intervention program in southern California. Overall, although NLB adults reported the greatest prevalence of tobacco use compared to NLWs and Latinos (43% vs. 34% and 22% respectively), associations between tobacco use, demographics and substance use were similar across groups. Males, younger individuals, those with lower income, and being at higher risk for alcohol and drug use were more likely to report recent tobacco use. Future tobacco interventions in emergency settings should highlight these specific risk factors for Latinos, NLBs, and NLWs.
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Affiliation(s)
- Cameron T McCabe
- Center for Alcohol and Drug Studies, San Diego, CA 92120, United States.
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A Critical Evaluation of the Impact of Leapfrog's Evidence-Based Hospital Referral. J Am Coll Surg 2011; 212:150-159.e1. [DOI: 10.1016/j.jamcollsurg.2010.09.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 09/14/2010] [Accepted: 09/29/2010] [Indexed: 12/17/2022]
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