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Wright K, Squires S, Cisco R, Trickey A, Kebebew E, Suh I, Seib CD. Disparities in access to high-volume parathyroid surgeons in the United States: A call to action. Surgery 2024; 175:48-56. [PMID: 37940435 PMCID: PMC10942749 DOI: 10.1016/j.surg.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/13/2023] [Accepted: 03/30/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Parathyroidectomy by a high-volume surgeon is associated with a reduced risk of perioperative complications and of failure to cure primary and secondary hyperparathyroidism. There are limited data on disparities in access to high-volume parathyroid surgeons in the United States. METHODS We used publicly available 2019 Medicare Provider Utilization and Payment data to identify all surgeons who performed >10 parathyroidectomies for Medicare fee-for-service beneficiaries, anticipating that fee-for-service beneficiaries likely represent only a subset of their high-volume practices. High-volume parathyroid surgeon characteristics and geographic distribution were evaluated. Inequality in the distribution of surgeons was measured by the Gini coefficient. The association between neighborhood disadvantage, based on the Area Deprivation Index, and proximity to high-volume parathyroid surgeons was evaluated using a one-way analysis of variance with Bonferroni-corrected pairwise comparisons. A sensitivity analysis was performed restricting to high-volume parathyroid surgeons within each hospital referral region, evidence-based regional markets for tertiary medical care. RESULTS We identified 445 high-volume parathyroid surgeons who met inclusion criteria with >10 parathyroidectomies for Medicare fee-for-service beneficiaries. High-volume parathyroid surgeons were 71% male sex, and 59.8% were general surgeons. High-volume parathyroid surgeons were more likely to practice in a Metropolitan Statistical Area with a population >1 million than in less populous metropolitan or rural areas. The number of high-volume parathyroid surgeons per 100,000 fee-for-service Medicare beneficiaries in the 53 most populous Metropolitan Statistical Areas ranged from 0 to 4.94, with the highest density identified in Salt Lake City, Utah. In 2019, 50% of parathyroidectomies performed by high-volume parathyroid surgeons were performed by 20% of surgeons in this group, suggesting unequal distribution of surgical care (Gini coefficient 0.41). Patients in disadvantaged neighborhoods were farther from high-volume parathyroid surgeons than those in advantaged neighborhoods (median distance: disadvantaged 27.8 miles, partially disadvantaged 20.7 miles, partially advantaged 12.1 miles, advantaged 8.4 miles; P < .001). This association was also shown in the analysis of distance to high-volume parathyroid surgeons within the hospital referral region (P < .001). CONCLUSION Older adults living in disadvantaged neighborhoods have less access to high-volume parathyroid surgeons, which may adversely affect treatment and outcomes for patients with primary and secondary hyperparathyroidism. This disparity highlights the need for actionable strategies to provide equitable access to care, including improved regionalization of high-volume parathyroid surgeon services and easing travel-related burdens for underserved patients.
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Affiliation(s)
- Kyla Wright
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | | | - Robin Cisco
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Amber Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Insoo Suh
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Carolyn D Seib
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA.
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Bakillah E, Brown D, Syvyk S, Wirtalla C, Kelz RR. Barriers and facilitators to surgical access in underinsured and immigrant populations. Am J Surg 2023; 226:176-185. [PMID: 37156680 DOI: 10.1016/j.amjsurg.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/10/2023] [Accepted: 04/08/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Marginalized communities are at risk of receiving inequitable access to surgical care. We aimed to examine the barriers and facilitators to access to surgery in underinsured and immigrant populations. METHODS A systematic review of disparities in access to surgical care was performed between January 1, 2000-March 2, 2022. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A convergent integrated approach was used to code common themes between studies. RESULTS Of 1315 publications, a total of 66 studies were included for systematic review. Eight studies specifically discussed immigrant patient populations. Barriers and facilitators to surgical access were categorized by patient and health systems related factors. CONCLUSIONS Established facilitators to improve surgical access are centered on patient-level factors while interventions to address systems-related barriers are limited and may be an area for further investigation. Research focused on access to surgery in immigrant populations remains sparse.
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Affiliation(s)
- Emna Bakillah
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Danielle Brown
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Solomiya Syvyk
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Christopher Wirtalla
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Rachel R Kelz
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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3
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Cohen BD, Aminpour N, Wang H, Sellke FW, Al-Refaie WB, Ehsan A. Did ethno-racial disparities in access to transcatheter aortic valve replacement change over time? JTCVS OPEN 2022; 12:71-83. [PMID: 36590742 PMCID: PMC9801242 DOI: 10.1016/j.xjon.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/25/2022] [Accepted: 07/01/2022] [Indexed: 01/04/2023]
Abstract
Objective In this study we sought to evaluate whether disparate use of transcatheter aortic valve replacement (TAVR) among non-White patients has decreased over time, and if unequal access to TAVR is driven by unequal access to high-volume hospitals. Methods From 2013 to 2017, we used the State Inpatient Database across 8 states (Ariz, Colo, Fla, Md, NC, NM, Nev, Wash) to identify 51,232 Medicare beneficiaries who underwent TAVR versus surgical aortic valve replacement. Hospitals were categorized as low- (<50 per year), medium- (50-100 per year), or high-volume (>100 per year) according to total valve procedures (TAVR + surgical aortic valve replacement). Multivariable logistic regression models with interactions were performed to determine the effect of race, time, and hospital volume on the utilization of TAVR. Results Non-White patients were less likely to receive TAVR than White patients (odds ratio [OR], 0.77; 95% CI, 0.71-0.83). However, utilization of TAVR increased over time (OR, 1.73; 95% CI, 1.73-1.80) for the total population, with non-White patients' TAVR use growing faster than for White patients (OR, 1.06; 95% CI, 1.00-1.12), time × race interaction, P = .034. Further, an adjusted volume-stratified time trend analysis showed that utilization of TAVR at high volume hospitals increased faster for non-White patients versus White patients by 8.6% per year (OR, 1.09; 95% CI, 1.01-1.16) whereas use at low- and medium-volume hospitals did not contribute to any decreasing utilization gap. Conclusions This analysis shows initial low rates of TAVR utilization among non-White patients followed by accelerated use over time, relative to White patients. This narrowing gap was driven by increased TAVR utilization by non-White patients at high-volume hospitals.
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Affiliation(s)
- Brian D. Cohen
- Department of Surgery, MedStar Georgetown/Washington Hospital Center, Washington, DC
| | | | - Haijun Wang
- MedStar Health Research Institute, Hyattsville, Md
| | - Frank W. Sellke
- Division of Cardiothoracic Surgery, Brown University Medical School/Rhode Island Hospital, Providence, RI
| | - Waddah B. Al-Refaie
- Department of Surgery, MedStar Georgetown University Hospital, Washington, DC,Address for reprints: Waddah B. Al-Refaie, MD, FACS, MedStar Georgetown University Hospital, MedStar-Georgetown Surgical Outcomes Research Center, Georgetown Lombardi Comprehensive Cancer Center, 3800 Reservoir Rd NW, PHC Building, 4th Floor, Washington, DC 20007.
| | - Afshin Ehsan
- Division of Cardiothoracic Surgery, Brown University Medical School/Rhode Island Hospital, Providence, RI
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Park E, Park H, Kang D, Chung CR, Yang JH, Jeon K, Guallar E, Cho J, Suh GY, Cho J. Health disparities of critically ill children according to poverty: the Korean population-based retrospective cohort study. BMC Public Health 2021; 21:1274. [PMID: 34193092 PMCID: PMC8243750 DOI: 10.1186/s12889-021-11324-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 06/18/2021] [Indexed: 01/09/2023] Open
Abstract
Background There is a lack of nationwide studies on critically ill patients’ health disparity under the National Health Insurance (NHI) system. We evaluated health disparities in intensive care unit (ICU) admission, outcomes, and readmission in impoverished children. Methods We conducted a retrospective cohort study using a national database from the Korean NHI and Medical Aid Program (MAP). MAP supports the population whose household income is lower than 40% of the median Korean household income. We defined poverty as being a MAP beneficiary and compared the poverty and non-poverty groups. Patients between 28 days and 18 years old who were admitted to the ICU were included. Hospital mortality and readmission were analyzed with adjustment for patient characteristics, hospital type, and management procedures. Results Out of 17,893 patients, 1153 (6.4%) patients were in poverty. The age-standardized ICU admission rate was higher in the poverty group (126.9 vs. 80.2 per 100,000 person-years). There was more age-standardized mortality in the poverty group (11.8 vs. 4.3 per 100,000 person-years). Patients in the poverty group did not have a statistically different risk of adjusted in-hospital mortality to those in the non-poverty group (odds ratio: 1.15, confidence interval [CI]: 0.84–1.55) but had a higher readmission rate (hazard ratio 1.25, CI 1.09–1.42). Conclusion Under the NHI system, the disparity in pediatric critical care outcomes according to poverty is not definite, but the healthcare disparity in pre- and post-hospital care is a concern. Further studies are required to improve pre- and post-hospital healthcare quality of impoverished children. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11324-4.
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Affiliation(s)
- Esther Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Hyejeong Park
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
| | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea.,Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Eliseo Guallar
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea.,Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Medicine, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea.,Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Joongbum Cho
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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de Jager E, Levine AA, Udyavar NR, Burstin HR, Bhulani N, Hoyt DB, Ko CY, Weissman JS, Britt LD, Haider AH, Maggard-Gibbons MA. Disparities in Surgical Access: A Systematic Literature Review, Conceptual Model, and Evidence Map. J Am Coll Surg 2020; 228:276-298. [PMID: 30803548 DOI: 10.1016/j.jamcollsurg.2018.12.028] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 01/17/2023]
Affiliation(s)
- Elzerie de Jager
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA; College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Adele A Levine
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - N Rhea Udyavar
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | | | - Nizar Bhulani
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | | | - Clifford Y Ko
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - L D Britt
- Department of Surgery, Eastern Virginia Medical School, Norfolk, VA
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - Melinda A Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA.
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6
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Johnson A. Understanding Why Black Patients Have Worse Coronary Heart Disease Outcomes: Does the Answer Lie in Knowing Where Patients Seek Care? J Am Heart Assoc 2019; 8:e014706. [PMID: 31787054 PMCID: PMC6912985 DOI: 10.1161/jaha.119.014706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Amber Johnson
- University of Pittsburgh School of Medicine Pittsburgh PA
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7
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Racial variations in extracorporeal membrane oxygenation use following congenital heart surgery. J Thorac Cardiovasc Surg 2018; 156:306-315. [PMID: 29681396 DOI: 10.1016/j.jtcvs.2018.02.103] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 02/09/2018] [Accepted: 02/15/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Previous studies demonstrate racial and ethnic disparities among children undergoing congenital heart surgery. Extracorporeal membrane oxygenation (ECMO) is used to support critically ill children after congenital heart surgery and improve survival. Thus, racial or ethnic variations in postoperative ECMO use following congenital heart surgery may be associated with racial/ethnic disparities in hospital survival. METHODS All children in the Pediatric Health Information Systems dataset undergoing congenital heart surgery from 2004 to 2015 were examined. Multivariable, multinomial regression models examining hospital survival without ECMO use, survival after ECMO, death after ECMO, and death without ECMO support were constructed. RESULTS Of 130,860 congenital cardiac surgery patients, 95.4% survived to hospital discharge without requiring ECMO support, whereas 1.3% survived after ECMO support, 1.3% died after ECMO support, and 1.9% died without receiving ECMO support. After adjustment for other covariates, black patients (odds ratio, 1.22; 95% confidence interval [CI], 1.05-1.42) and patients of other race (odds ratio, 1.36; 95% CI, 1.17-1.58) were at increased odds of mortality compared with white patients. In multivariable multinomial models, black patients had increased risk of death without ECMO support (relative risk, 1.31; 95% CI, 1.11-1.56). Patients of other race (relative risk, 1.37; 95% CI, 1.10-1.69) and governmental insurance (relative risk, 1.24; 95% CI, 1.12-1.37) were also at increased risk of death without ECMO. CONCLUSIONS Black children and children of other race are at increased odds of mortality after congenital heart surgery. These disparities can be traced to variations in ECMO utilization across racial/ethnic groups.
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Abstract
OBJECTIVES Previous studies have suggested an association between nonwhite race and poor outcomes in small subsets of cardiac surgery patients who require extracorporeal life support. This study aims to examine the association of race/ethnicity with mortality in pediatric patients who receive extracorporeal life support for cardiac support. DESIGN Retrospective analysis of registry data. SETTING Prospectively collected multi-institutional registry data. SUBJECTS Data from all North American pediatric patients in the Extracorporeal Life Support International Registry who received extracorporeal life support for cardiac support between 1998 and 2012 were analyzed. Multivariate regression models were constructed to examine the association between race/ethnicity and hospital mortality, adjusting for demographics, diagnosis, pre-extracorporeal life support care, extracorporeal life support variables, and extracorporeal life support-related complications. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 7,106 patients undergoing cardiac extracorporeal life support, the majority of patients were of white race (56.9%) with black race (16.7%), Hispanic ethnicity (15.8%), and Asian race (2.8%) comprising the other major race/ethnic groups. The mortality rate was 53.9% (n = 3,831). After adjusting for covariates, multivariate analysis identified black race (relative risk = 1.10; 95% CI, 1.04-1.16) and Hispanic ethnicity (relative risk = 1.08; 95% CI, 1.02-1.14) as independent risk factors for mortality. CONCLUSIONS Black race and Hispanic ethnicity are independently associated with mortality in children who require cardiac extracorporeal life support.
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Vaez M, Dalén M, Friberg Ö, Nilsson J, Frøbert O, Lagerqvist B, Ivert T. Regional differences in coronary revascularization procedures and outcomes: a nationwide 11-year observational study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2017; 3:243-248. [DOI: 10.1093/ehjqcco/qcx007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/27/2017] [Indexed: 11/14/2022]
Abstract
Abstract
Aims
The study investigated whether regional differences in choice of coronary revascularization affected outcomes in Sweden.
Methods and results
We conducted a prospective nationwide study of outcome in patients undergoing coronary artery bypass grafting (CABG, n = 47 065) or percutaneous coronary intervention (PCI, n = 140 945) from 2001 through 2011, tracked for a median of 5 years. During this period, the proportion of CABG in revascularization procedures decreased nationwide from an average of 38% to 18%e. Three-vessel disease and left main stem coronary artery stenosis were more common among CABG patients than in PCI patients. In both males and females, all-cause mortality was higher in CABG patients than in PCI patients, while repeat PCI was performed more frequently in the PCI group. CABG proportions in 21 counties ranged from 13% to 42% in females and males. The combined outcomes of repeat revascularization, non-fatal acute myocardial infarction, and death during the tracking period was recorded in 151 936 patients without ST-elevation myocardial infarction after PCI (n = 37 820, 36%) and CABG (n = 18 903, 40%). The multivariable adjusted risk of combined outcomes was higher after both PCI and CABG in both females and males in the three quartiles of counties with a smaller proportion of CABG than in the quartile of counties with the highest proportion of CABG. Similar patterns persisted after including only mortality in the analyses.
Conclusion
There are subgroups of patients who have prognostic benefits of CABG in addition to symptomatic improvement that is well documented with both PCI and CABG.
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Affiliation(s)
- Marjan Vaez
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Dalén
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Örjan Friberg
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Sweden
| | - Johan Nilsson
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University, Skane University Hospital, Lund, Sweden
| | - Ole Frøbert
- Faculty of Health, Department of Cardiology, Örebro University Hospital, Örebro University, Sweden
| | - Bo Lagerqvist
- Department of Medical Sciences, Cardiology Section, Uppsala Clinical, Research Center, Uppsala University, Uppsala, Sweden
| | - Torbjörn Ivert
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Medicaid beneficiaries undergoing complex surgery at quality care centers: insights into the Affordable Care Act. Am J Surg 2016; 211:750-4. [PMID: 26874897 DOI: 10.1016/j.amjsurg.2015.11.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 10/07/2015] [Accepted: 11/06/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Medicaid beneficiaries do not have equal access to high-volume centers for complex surgical procedures. We hypothesize there is a large Medicaid Gap between those receiving emergency general vs complex surgery at the same hospital. METHODS Using the Nationwide Inpatient Sample, 1998 to 2010, we identified high-volume pancreatectomy hospitals. We then compared the percentage of Medicaid patients receiving appendectomies vs pancreatectomies at these hospitals. Hospital characteristics associated with increased Medicaid Gap were evaluated using generalized estimating equation models. RESULTS A total of 602 hospital-years of data from 289 high-volume pancreatectomy hospitals were included. Median percentages of Medicaid appendectomies and pancreatectomies were 12.1% (interquartile range: 5.8% to 19.8%) and 6.7% (interquartile range: 0% to 15.4%), respectively. Hospitals that performed greater than or equal to 40 pancreatic resections per year had higher odds of having significant Medicaid Gap (odds ratio 2.3, 95% confidence interval 1.1 to 5.0). CONCLUSIONS Gaps exist between the percentages of Medicaid patients receiving emergency general surgery vs more complex surgical care at the same hospital and may be exaggerated in hospitals with very high volume of complex elective surgeries.
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Chan T, Lion KC, Mangione-Smith R. Racial disparities in failure-to-rescue among children undergoing congenital heart surgery. J Pediatr 2015; 166:812-8.e1-4. [PMID: 25556012 DOI: 10.1016/j.jpeds.2014.11.020] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 10/08/2014] [Accepted: 11/07/2014] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine if racial/ethnic disparities exist among children undergoing congenital heart surgery, using failure-to-rescue (FTR) as a measure of hospital-based quality. STUDY DESIGN This is a retrospective, repeated cross-sectional analysis using admissions from the 2003, 2006, and 2009 Kids' Inpatient Database. All pediatric admissions (≤ 18 years) with a Risk Adjustment for Congenital Heart Surgery procedure were included. Logistic regression models examining complications, FTR, and overall mortality were constructed. RESULTS Hispanic ethnicity (OR 1.13, 95% CI 1.01-1.26) was associated with increased odds of experiencing a complication when compared with white race. However, black race (OR 1.66, 95% CI 1.33-2.07) and other race/ethnicity (OR 1.40, 95% CI 1.10-1.79) were risk factors for FTR. Although Hispanic ethnicity was associated with increased odds of experiencing a complication, it was not associated with FTR. In hospital fixed-effects models, black race and other race/ethnicity remained as "within hospital" risk factors for FTR. CONCLUSIONS Black children and children of other race/ethnicity had higher rates of mortality after experiencing a complication. This suggests that racial disparities may exist in hospital-based cardiac care or response to care.
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Affiliation(s)
- Titus Chan
- Department of Pediatrics, University of Washington, Seattle, WA; Division of Critical Care Medicine and the Heart Center, Seattle Children's Hospital, Seattle, WA
| | - K Casey Lion
- Department of Pediatrics, University of Washington, Seattle, WA; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, WA; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA
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Efird JT, O'Neal WT, Griffin WF, Anderson EJ, Davies SW, Landrine H, O'Neal JB, Shiue KY, Kindell LC, Bruce Ferguson T, Randolph Chitwood W, Kypson AP. Increased coronary artery disease severity in black women undergoing coronary bypass surgery. Medicine (Baltimore) 2015; 94:e552. [PMID: 25700324 PMCID: PMC4554167 DOI: 10.1097/md.0000000000000552] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Race and sex disparities are believed to play an important role in heart disease. The purpose of this study was to examine the association between race, sex, and number of diseased vessels at the time of coronary artery bypass grafting (CABG), and subsequent postoperative outcomes. The 13,774 patients undergoing first-time, isolated CABG between 1992 and 2011 were included. Trend in the number of diseased vessels between black and white patients, stratified by sex, were analyzed using a Cochran-Armitage trend test. Models were adjusted for age, procedural status (elective vs. nonelective), and payor type (private vs. nonprivate insurance). Black female CABG patients presented with an increasingly greater number of diseased vessels than white female CABG patients (adjusted P(trend) = 0.0021). A similar trend was not observed between black and white male CABG patients (adjusted P(trend) = 0.18). Black female CABG patients were also more likely to have longer intensive care unit and hospital lengths of stay than other race-sex groups.Our findings suggest that black female CABG patients have more advanced coronary artery disease than white female CABG patients. Further research is needed to determine the benefit of targeted preventive care and preoperative workup for this high-risk group.
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Affiliation(s)
- Jimmy T Efird
- From the Department of Cardiovascular Sciences (JTE, WFG, KYS, LCK, TBF, WRC, APK), East Carolina Heart Institute; Center for Health Disparities (JTE, HL), Brody School of Medicine, East Carolina University, Greenville; Department of Internal Medicine (WTO), Wake Forest School of Medicine, Winston-Salem; Department of Pharmacology and Toxicology (EJA), Brody School of Medicine, East Carolina University, Greenville, North Carolina; Department of General Surgery (SWD), University of Virginia School of Medicine, Charlottesville, Virginia; and Department of Anesthesia (JBO), Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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13
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Kim Y, Oh J, Jha A. Contribution of hospital mortality variations to socioeconomic disparities in in-hospital mortality. BMJ Qual Saf 2014; 23:741-8. [PMID: 24608101 DOI: 10.1136/bmjqs-2013-002744] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND While disparities in hospital care outcomes based on ethnicity or socioeconomic status have been documented in some nations, it is unclear to what extent this phenomenon occurs in high-income countries like Korea with relatively low income inequality. METHODS We examined in-hospital mortality rates for wealthy and poor patients in South Korea for five common medical conditions. We measured in-hospital mortality rates and examined within-hospital differences (wealthy and poor patients receive different care at the same institution) as well as between-hospital differences (wealthy and poor patients receiving care at different institutions) across socioeconomic status. We built multivariable models that adjusted for risk and further adjusted our analyses for hospital characteristics including a hospital's overall mortality ranking. RESULTS There were 127,438 patients with one of the five conditions examined nested in 66 Korean hospitals. We found moderate differences in mortality rates between wealthy and poor patients across four of the five conditions. These mortality differences were largely attributable to differences in mortality rates for wealthy patients compared with those for poor patients within the same hospital (within-hospital variation) while a relatively small portion of these disparities were attributable to mortality difference between hospitals where wealthy and poor patients seek care (between-hospital variation). For example, we estimate that improving care for poor patients in the same hospital can eliminate 86% of the disparities for acute myocardial infarction outcomes, while ensuring equal access to low mortality hospitals would reduce only 16% of the disparities in outcomes. CONCLUSIONS This study suggests that to reduce socioeconomic disparities in hospital mortality, interventions that target within-hospital effects may be more effective than interventions targeting between hospital effects.
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Affiliation(s)
- Yoon Kim
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Republic of Korea Institute of Health Policy and Management, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Juhwan Oh
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ashish Jha
- Department of Health Policy and Management, Harvard University, Boston, Massachusetts, USA
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Socioeconomic and Geographic Disparities in Access to Endovascular Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2013; 27:1061-7. [DOI: 10.1016/j.avsg.2013.02.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 01/25/2013] [Accepted: 02/05/2013] [Indexed: 11/20/2022]
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Forsyth CJ, Pathak EB, Strom JA. De Facto regionalization of care for ST-elevation myocardial infarction in Florida, 2001-2009. Am Heart J 2012; 164:681-8. [PMID: 23137498 DOI: 10.1016/j.ahj.2012.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 06/22/2012] [Indexed: 11/18/2022]
Abstract
ACC/AHA guidelines recommend STEMI patients receive percutaneous coronary intervention (PCI) at high volume hospitals performing ≥400 procedures/year. The objective of this study was to evaluate changes in the organization and implementation of care for STEMI patients in Florida. We assessed trends and predictors of STEMI patients first hospitalized at high PCI volume hospitals in Florida from 2001-2009. This is the first study to examine statewide trends in hospital admission for all STEMI patients. We classified Florida hospitals by PCI volume (high, medium, low, non-PCI) for each quarter from January, 2001 through June, 2009. Using hospital discharge data, we determined the percent of STEMI patients who went to each type of hospital and analyzed multiple predictors. From 2001-2009 the proportion of STEMI patients first hospitalized at high PCI volume hospitals rose from 62.4 to 89.7%, while admissions to non-PCI hospitals declined from 31% to 4.9%. Persistent barriers to high PCI volume hospital admission were age ≥85 years (OR 0.56, 95% CI 0.50-0.62), female gender (OR 0.85, 95% CI 0.79-0.91), and residence in a major metropolitan county. Through the efforts of local coalitions throughout Florida, by 2009 almost 90% of Florida STEMI patients were first admitted to high PCI volume hospitals. Greater hospital competition may explain lower admission rates to high PCI volume hospitals in major metropolitan counties. The age and gender disadvantage we observed requires further research to determine potential causes.
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Affiliation(s)
- Colin J Forsyth
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL 33612, USA.
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Hospital racial composition: a neglected factor in cardiac arrest survival disparities. Am Heart J 2011; 161:705-11. [PMID: 21473969 DOI: 10.1016/j.ahj.2011.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2010] [Accepted: 01/21/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Racial disparities in survival after out-of-hospital cardiac arrest have been reported, but their causes remain uncertain. We sought to determine if hospital racial composition accounted for survival differences for patients hospitalized after cardiac arrest. METHODS We evaluated hospitalizations of white and black Medicare beneficiaries (2000-2007) admitted from the emergency department to the intensive care unit with a diagnosis of cardiac arrest or ventricular fibrillation. We examined unadjusted survival rates and developed a multivariable logistic regression model that included patient and hospital factors. RESULTS We analyzed 68,115 cardiac arrest admissions. Unadjusted survival to hospital discharge was worse for blacks (n = 7,942) compared with whites (n = 60,173) (30% vs 33%, P < .001). In multivariate analyses accounting for patient and hospital factors, adjusted probability of survival was worse for black patients at hospitals with higher proportions of black patients (31%, 95% CI 29%-32%) compared with predominately white hospitals (46%, 95% CI 36%-57%; P = .003). Similarly, whites had worse risk-adjusted survival at hospitals with higher proportions of black patients (28%, 95% CI 27%-30%) compared with predominately white hospitals (32%, 95% CI 31%-33%, P = .006). Blacks were more likely to be admitted to hospitals with low survival rates (23% vs 15%, P < .001). CONCLUSION Hospitals with large black patient populations had worse cardiac arrest outcomes than predominantly white hospitals, and blacks were more likely to be admitted to these high-mortality hospitals. Understanding these differences in survival outcomes may uncover the causes for these disparities and lead to improved survival for all cardiac arrest victims.
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