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Kempe K, Homco J, Nsa W, Wetherill M, Jelley M, Lesselroth B, Hasenstein T, Nelson PR. Analysis of Oklahoma amputation trends and identification of risk factors to target areas for limb preservation interventions. J Vasc Surg 2024; 80:515-526. [PMID: 38604318 DOI: 10.1016/j.jvs.2024.03.446] [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: 01/13/2024] [Revised: 03/15/2024] [Accepted: 03/15/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Annual trends of lower extremity amputation due to end-stage chronic disease are on the rise in the United States. These amputations are leading to massive expenses for patients and the medical system. In Oklahoma, we have a high-risk population because access to care is low, the number of uninsured is high, cardiovascular health is poor, and our overall health care performance is ranked 50th in the country. But we know little about Oklahomans and their risk of limb loss. It is, therefore, imperative to look closely at this population to discover contemporary rates, trends, and state-specific risk factors for amputation due to diabetes and/or peripheral arterial disease (PAD). We hypothesize that state-specific groups will be identified as having the highest risk for limb loss and that contemporary trends in amputations are rising. To create implementable solutions to limb preservation, a baseline must be set. METHODS We conducted a 12-consecutive-year observational study using Oklahoma's hospital discharge data. Discharges among patients 20 years or older with a primary or secondary diagnosis of diabetes and/or PAD were included. Diagnoses and amputation procedures were identified using International Classification of Disease-9 and -10 codes. Amputation rates were calculated per 1000 discharges. Trends in amputation rates were measured by annual percentage changes (APC). Prevalence ratios evaluated the differences in amputation rates across demographic groups. RESULTS Over 5,000,000 discharges were identified from 2008 to 2019. Twenty-four percent had a diagnosis of diabetes and/or PAD. The overall amputation rate was 12 per 1000 discharges for those with diabetes and/or PAD. Diabetes and/or PAD-related amputation rates increased from 8.1 to 16.2 (APC, 6.0; 95% confidence interval [CI], 4.7-7.3). Most amputations were minor (59.5%), and although minor, increased at a faster rate compared with major amputations (minor amputation APC, 8.1; 95% CI, 6.7-9.6 vs major amputation APC, 3.1; 95% CI, 1.5-4.7); major amputations were notable in that they were significantly increasing. Amputation rates were the highest among males (16.7), American Indians (19.2), uninsured (21.2), non-married patients (12.7), and patients between 45 and 49 years of age (18.8), and calculated prevalence ratios for each were significant (P = .001) when compared within their respective category. CONCLUSIONS Amputation rates in Oklahoma have nearly doubled in 12 years, with both major and minor amputations significantly increasing. This study describes a worsening trend, underscoring that amputations due to chronic disease is an urgent statewide health care problem. We also present imperative examples of amputation health care disparities. By defining these state-specific areas and populations at risk, we have identified areas to pursue and improve care. These distinctive risk factors will help to frame a statewide limb preservation intervention.
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Affiliation(s)
- Kelly Kempe
- University of Oklahoma Health Sciences Center, School of Community Medicine, Department of Surgery, Tulsa, OK.
| | - Juell Homco
- University of Oklahoma Health Sciences Center, School of Community Medicine, Department of Medical Informatics, Tulsa, OK
| | - Wato Nsa
- University of Oklahoma Health Sciences Center, School of Community Medicine, Department of Medical Informatics, Tulsa, OK
| | - Marianna Wetherill
- University of Oklahoma Health Sciences Center, Hudson College of Public Health, Tulsa, OK
| | - Martina Jelley
- University of Oklahoma Health Sciences Center, School of Community Medicine, Department of Medicine, Tulsa, OK
| | - Blake Lesselroth
- University of Oklahoma Health Sciences Center, School of Community Medicine, Department of Medical Informatics, Tulsa, OK
| | - Todd Hasenstein
- University of Oklahoma Health Sciences Center, School of Community Medicine, Department of Surgery, Tulsa, OK
| | - Peter R Nelson
- University of Oklahoma Health Sciences Center, School of Community Medicine, Department of Surgery, Tulsa, OK
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Ramadan OI, Kelz RR, Sharpe JE, Wirtalla CJ, Keele LJ, Harhay MO, Roberts SE, Wang GJ. Impact of Medicaid expansion on outcomes after abdominal aortic aneurysm repair. J Vasc Surg 2023; 78:648-656.e6. [PMID: 37116595 DOI: 10.1016/j.jvs.2023.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 04/04/2023] [Accepted: 04/17/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE Lack of insurance has been independently associated with an increased risk of in-hospital mortality after abdominal aortic aneurysm repair, possibly due to worse control of comorbidities and delays in diagnosis and treatment. Medicaid expansion has improved insurance rates and access to care, potentially benefiting these patients. We sought to assess the association between Medicaid expansion and outcomes after abdominal aortic aneurysm repair. METHODS A retrospective analysis of Healthcare Cost and Utilization Project State Inpatient Databases data from 14 states between 2012 and 2018 was conducted. The sample was restricted to first-record abdominal aortic aneurysm repairs in adults under age 65 in states that expanded Medicaid on January 1, 2014 (Medicaid expansion group) or had not expanded before December 31, 2018 (non-expansion group). The Medicaid expansion and non-expansion groups were compared between pre-expansion (2012-2013) and post-expansion (2014-2018) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors, open vs endovascular repair, and standard errors clustered by state. Our primary outcome was in-hospital mortality. Outcomes were stratified by insurance type. RESULTS We examined 8995 patients undergoing abdominal aortic aneurysm repair, including 3789 (42.1%) in non-expansion states and 5206 (57.9%) in Medicaid expansion states. Rates of Medicaid insurance were unchanged in non-expansion states but increased in Medicaid expansion states post-expansion (non-expansion: 10.9% to 9.8%; P = .346; expansion: 9.7% to 19.7%; P < .001). One in 10 patients from both non-expansion and Medicaid expansion states presented with ruptured aneurysms, which did not change over time. Rates of open repair decreased in both non-expansion and Medicaid expansion states over time (non-expansion: 25.1% to 19.2%; P < .001; expansion: 25.2% to 18.4%; P < .001). On adjusted difference-in-differences analysis between expansion and non-expansion states pre-to post-expansion, Medicaid expansion was associated with a 1.02% absolute reduction in in-hospital mortality among all patients (95% confidence interval, -1.87% to -0.17%; P = .019). Additionally, among patients who were either on Medicaid or were uninsured (ie, the patients most likely to be impacted by Medicaid expansion), a larger 4.17% decrease in in-hospital mortality was observed (95% confidence interval, -6.47% to -1.87%; P < .001). In contrast, no significant difference-in-difference in mortality was observed for privately insured patients. CONCLUSIONS Medicaid expansion was associated with decreased in-hospital mortality after abdominal aortic aneurysm repair among all patients and particularly among patients who were either on Medicaid or were uninsured. Our results provide support for improved access to care for patients undergoing abdominal aortic aneurysm repair through Medicaid expansion.
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Affiliation(s)
- Omar I Ramadan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Rachel R Kelz
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - James E Sharpe
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | | | - Luke J Keele
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Michael O Harhay
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sanford E Roberts
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Witrick B, Kalbaugh CA, Mayo R, Hendricks B, Shi L. Disparities in healthcare utilization by insurance status among patients with symptomatic peripheral artery disease. BMC Health Serv Res 2023; 23:913. [PMID: 37641048 PMCID: PMC10463334 DOI: 10.1186/s12913-023-09862-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/29/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Peripheral artery disease (PAD) is a common circulatory disorder associated with increased hospitalizations and significant health care-related expenditures. Among patients with PAD, insurance status is an important determinant of health care utilization, treatment of disease, and treatment outcomes. However, little is known about PAD-costs differences across different insurance providers. In this study we examined possible disparities in length of stay and total charge of inpatient hospitalizations among patients with PAD by insurance type. METHODS We conducted a cross-sectional analysis of length of stay and total charge by insurance provider for all hospitalizations for individuals with PAD in South Carolina (2010-2018). Cross-classified multilevel modeling was applied to account for the non-nested hierarchical structure of the data, with county and hospital included as random effects. Analyses were adjusted for patient age, race/ethnicity, county, year of admission, admission type, all-patient refined diagnostic groups, and Charlson comorbidity index. RESULTS Among 385,018 hospitalizations for individuals with PAD in South Carolina, the median length of stay was 4 days (IQR: 5) and the median total charge of hospitalization was $43,232 (IQR: $52,405). Length of stay and total charge varied significantly by insurance provider. Medicare patients had increased length of stay (IRR = 1.08, 95 CI%: 1.07, 1.09) and higher total charges (β: 0.012, 95% CI: 0.007, 0.178) than patients with private insurance. Medicaid patients also had increased length of stay (IRR = 1.26, 95% CI: 1.24,1.28) but had lower total charges (β: -0.022, 95% CI: -0.003. -0.015) than patients with private insurance. CONCLUSIONS Insurance status was associated with inpatient length of stay and total charges in patients with PAD. It is essential that Medicare and Medicaid individuals with PAD receive proper management and care of their PAD, particularly in the primary care settings, to prevent hospitalizations and reduce the excess burden on these patients.
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Affiliation(s)
- Brian Witrick
- West Virginia Clinical and Translational Sciences Institute, PO Box 9102, Morgantown, WV, 26506-9102, USA.
| | - Corey A Kalbaugh
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, IN, USA
| | - Rachel Mayo
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - Brian Hendricks
- West Virginia Clinical and Translational Sciences Institute, PO Box 9102, Morgantown, WV, 26506-9102, USA
- Department of Epidemiology and Biostatistics, West Virginia University School of Public Health, Morgantown, WV, USA
| | - Lu Shi
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
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Ferdinand KC, Sadik K, Browne R, Desai U, Lefebvre P, Lejeune D, Mahendran M, Laliberté F, Matay L, Armstrong DG. Real-World Racial Variation in Treatment and Outcomes Among Patients with Peripheral Artery Disease. Adv Ther 2023; 40:1850-1866. [PMID: 36877443 PMCID: PMC10070216 DOI: 10.1007/s12325-023-02465-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/14/2023] [Indexed: 03/07/2023]
Abstract
INTRODUCTION Prior studies have found considerable disparities in prevalence and outcomes for patients with peripheral arterial disease (PAD). This study compared rates of diagnostic testing, treatment patterns, and outcomes after diagnosis of PAD among commercially insured Black and White patients in the United States. METHODS Optum's de-identified Clinformatics® Data Mart Database (1/2016-6/2021) were used to identify Black and White patients with PAD; first PAD diagnosis was deemed study index date. Baseline demographics, markers of disease severity, and healthcare costs were compared between cohorts. Patterns of medical management and rates of major adverse limb events (MALE; including acute or chronic limb ischemia, lower-limb amputation) and cardiovascular (CV) events (stroke, myocardial infarction) during the available follow-up period were described. Outcomes were compared between cohorts using multinomial logistic regression models, Kaplan-Meier survival analysis, and Cox proportional hazards models. RESULTS A total of 669,939 patients were identified, with 454,382 White patients and 96,162 Black patients. Black patients were younger on average (71.8 years vs. 74.2 years), but had higher comorbid burden, concomitant risk factors, and CV medication use at baseline. Prevalence of diagnostic testing, revascularization procedures, and medication use was numerically higher among Black patients. Black patients were also more likely than the White patients to receive medical therapy without a revascularization procedure [adjusted odds ratio with 95% confidence interval (CI) = 1.47 (1.44-1.49)]. However, Black patients with PAD had higher incidence of MALE and CV events than White patients [adjusted hazard ratio for composite event (95% CI) = 1.13, (1.11-1.15)]. Except myocardial infarction, the hazards of individual components of MALE and CV events were also significantly higher among Black patients with PAD. CONCLUSIONS Results of this real-world study suggest that Black patients with PAD have higher disease severity at the time of diagnosis and are at increased risk of experiencing adverse outcomes following diagnosis.
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Affiliation(s)
| | - Kay Sadik
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | | | - Urvi Desai
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA.
| | | | | | | | | | - Lisa Matay
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA
| | - David G Armstrong
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Fereydooni A, Patel J, Dossabhoy SS, George EL, Arya S. Racial, ethnic, and socioeconomic inequities in amputation risk for patients with peripheral artery disease and diabetes. Semin Vasc Surg 2023; 36:9-18. [PMID: 36958903 DOI: 10.1053/j.semvascsurg.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/26/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023]
Abstract
Peripheral artery disease and diabetes are highly prevalent diseases and the leading cause of limb loss. Despite advances in medical and surgical techniques, there are stark differences in delivery and outcomes of lower extremity amputation among populations when stratified by race, ethnicity, and socioeconomic status. We reviewed studies from the last 2 decades (1999-2022) to provide a comprehensive assessment of the current impact of disparities on the risk for, and management of, lower extremity amputation and offer action items that can optimize health outcomes.
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Affiliation(s)
- Arash Fereydooni
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, 780 Welch Road, Palo Alto, CA 94304
| | - Janhavi Patel
- Michael G. DeGroote School of Medicine, Michael G. DeGroote Centre for Learning and Discovery, Hamilton, Ontario, Canada
| | - Shernaz S Dossabhoy
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, 780 Welch Road, Palo Alto, CA 94304
| | - Elizabeth L George
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, 780 Welch Road, Palo Alto, CA 94304; Surgery Service Line, Veterans Affairs Palo Alto Healthcare System, 3801 Miranda Avenue, Palo Alto, CA 94304
| | - Shipra Arya
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, 780 Welch Road, Palo Alto, CA 94304; Surgery Service Line, Veterans Affairs Palo Alto Healthcare System, 3801 Miranda Avenue, Palo Alto, CA 94304.
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Bidare D, Sharath S, Cerise F, Barshes NR. Specialist access and leg amputations among Texas Medicaid patients. Semin Vasc Surg 2023; 36:49-57. [PMID: 36958897 DOI: 10.1053/j.semvascsurg.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/05/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022]
Abstract
Medicaid coverage among patients with peripheral artery disease (PAD) has been associated with higher rates of primary amputations. We sought to determine the relative contributions of clinical, demographic, and hospital factors to leg amputations among Texas Medicaid patients. Patient-level data were used to identify patients who underwent treatment for PAD-related foot complications in Texas. Patients were categorized into groups by insurance provider (Medicaid, Medicare, dual-enrollee, commercial, and provider network). Individual- and area-level multivariate analyses were used to find associations with primary amputation. Of 21,592 patients identified, 8.8% were covered by Medicaid, 35.3% by Medicare, 27.8% by Medicare and Medicaid, 7.3% by commercial insurance, and 20.7% by a provider network. Compared with commercially insured patients, Medicaid patients more often underwent amputation (33% v 49%), were categorized as Black or Hispanic (45% v 64%), presented with gangrene (61% v 71%), were admitted through an emergency department (61% v 73%), and were admitted to a safety net hospital (3% v 16%). They had lower relative rates of outpatient evaluation (1.33 v 0.55) and their hospitalizations were less centralized (Gini coefficient 0.43 v 0.39) (P < .001 for all). Amputations among Medicaid patients were associated with infection and gangrene, care at safety net hospitals, rate of outpatient visits, and Black and Hispanic race, even after risk-adjustment (P < .001). Leg amputations among Medicaid patients were associated with race, disease severity, hospital characteristics, and outpatient evaluation rates, but not with provider density and location. Focusing efforts on preventative care and early outpatient referrals could help address this disparity.
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Affiliation(s)
- Deeksha Bidare
- Department of Student Affairs, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030.
| | - Sherene Sharath
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | | | - Neal R Barshes
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
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Dockery DM, Nwaiwu CA, Liu Y, Green A, Licht AH, Ewala S, Leal D, Moreira CC. Dual-eligible, dual-risk? A brief review on the impact of dual-eligible status on health disparities and peripheral artery disease. Semin Vasc Surg 2023; 36:64-68. [PMID: 36958899 DOI: 10.1053/j.semvascsurg.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/19/2022] [Accepted: 12/24/2022] [Indexed: 12/29/2022]
Abstract
Peripheral artery disease (PAD) has been associated with poorer outcomes based on particular social determinants of health, including insurance status. A unique population to study treatment outcomes related to PAD is those with dual-eligible status-those who qualify for both Medicare and Medicaid-comprising more than 12 million people. We performed a systematic review of the literature surrounding dual-eligible patients and impact on PAD, with final inclusion of six articles. Dual eligibility has been associated with higher rates of comorbidities; more severe symptoms at initial presentation for PAD; and poorer treatment outcomes, including mortality. Further studies are needed to specifically look at the association between PAD and dual-eligible status, but what is clear is that patients in this population would benefit from early identification to prevent disease progression and improve equity.
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Affiliation(s)
- Dominique M Dockery
- Warren Alpert Medical School of Brown University, Providence, RI; Supporting Underrepresented Research to Generate Equity (SURGE) Laboratory, Warren Alpert Medical School of Brown University, Providence, RI
| | - Chibueze A Nwaiwu
- Supporting Underrepresented Research to Generate Equity (SURGE) Laboratory, Warren Alpert Medical School of Brown University, Providence, RI; Department of Surgery, Lifespan Health System and Warren Alpert Medical School of Brown University, Providence, RI
| | - Yao Liu
- Supporting Underrepresented Research to Generate Equity (SURGE) Laboratory, Warren Alpert Medical School of Brown University, Providence, RI; Department of Surgery, Lifespan Health System and Warren Alpert Medical School of Brown University, Providence, RI
| | - Adrienne Green
- Supporting Underrepresented Research to Generate Equity (SURGE) Laboratory, Warren Alpert Medical School of Brown University, Providence, RI
| | - Aron H Licht
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Stanley Ewala
- Supporting Underrepresented Research to Generate Equity (SURGE) Laboratory, Warren Alpert Medical School of Brown University, Providence, RI
| | - Dayann Leal
- Supporting Underrepresented Research to Generate Equity (SURGE) Laboratory, Warren Alpert Medical School of Brown University, Providence, RI
| | - Carla C Moreira
- Supporting Underrepresented Research to Generate Equity (SURGE) Laboratory, Warren Alpert Medical School of Brown University, Providence, RI; Department of Surgery, Lifespan Health System and Warren Alpert Medical School of Brown University, Providence, RI; Division of Vascular Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, 2 Dudley Street, Suite 470, Providence, RI 02905.
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Ramadan OI, Santos T, Stoecker JB, Belkin N, Jackson BM, Schneider DB, Rice J, Wang GJ. The Differential Impact of Medicaid Expansion on Disparities in Outcomes Following Peripheral Vascular Intervention. Ann Vasc Surg 2022; 86:135-143. [PMID: 35460861 DOI: 10.1016/j.avsg.2022.04.016] [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: 12/19/2021] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Peripheral artery disease (PAD) disproportionately affects nonwhite, Hispanic/Latino, and low socioeconomic status patients, who are less likely to have insurance and routine healthcare visits. Medicaid expansion (ME) has improved insurance rates and access to care, potentially benefitting these patients. We sought to assess the impact of ME on disparities in outcomes after peripheral vascular intervention (PVI) for PAD. METHODS A retrospective analysis of prospectively-collected Vascular Quality Initiative PVI procedures between 2011 and 2019 was conducted. The sample was restricted to first-record procedures in adults under the age 65 in states that expanded Medicaid on January 1, 2014 (ME group) or had not expanded before January 1, 2019 (non-expansion [NE] group). ME and NE groups were compared between pre-expansion (2011-2013) and post-expansion (2014- 2019) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors and clinical center and year fixed effects. Our primary outcome was 1-year major amputation. Secondary outcomes included trends in presentation, 30-day mortality, 1-year mortality, and 1-year primary and secondary patency. Outcomes were stratified by race and ethnicity. RESULTS We examined 34,313 PVI procedures, including 20,378 with follow-up data. Rates of Medicaid insurance increased post-expansion in ME and NE states (ME 16.7% to 23.0%, P < 0.001; NE 10.0% to 11.9%, P = 0.013) while rates of self-pay decreased in ME states only (ME 4.6% to 1.8%, P < 0.001; NE 8.1% to 8.4%, P = 0.620). Adjusted difference-in-differences analysis revealed lower odds of urgent/emergent PVI among all patients and all nonwhite patients in ME states post-expansion compared to NE states (all: odds ratio [OR] 0.53 [95% confidence interval 0.33-0.87], P = 0.011; nonwhite: OR 0.41 [0.19-0.88], P = 0.023). No differences were observed for 1-year major amputation (OR 0.70 [0.43-1.14], P = 0.152), primary patency (OR 0.93 [0.63-1.38], P = 0.726), or secondary patency (OR 1.29 [0.69-2.41], P = 0.431). Odds of 1-year mortality were higher in ME states post-expansion compared to NE states (OR 2.50 [1.07-5.87], P = 0.035), although 30-day mortality was not different (OR 2.04 [0.60-6.90], P = 0.253). Notably, odds of 1-year major amputation among Hispanic/Latino patients decreased in ME states post-expansion compared to NE states (OR 0.11 [0.01-0.86], P = 0.036). CONCLUSIONS ME was associated with lower odds of 1-year major amputation among Hispanic/Latino patients who underwent PVI for PAD. ME was also associated with lower odds of urgent/emergent procedures among patients overall and nonwhite patients specifically. However, 1-year mortality increased in the overall cohort. Further study is needed to corroborate our findings that ME may have benefits for certain underserved populations with PAD.
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Affiliation(s)
- Omar I Ramadan
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Tatiane Santos
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; The Wharton School at the University of Pennsylvania, Philadelphia, PA
| | - Jordan B Stoecker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Nathan Belkin
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Benjamin M Jackson
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Darren B Schneider
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jayne Rice
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Demsas F, Joiner MM, Telma K, Flores AM, Teklu S, Ross EG. Disparities in peripheral artery disease care: A review and call for action. Semin Vasc Surg 2022; 35:141-154. [PMID: 35672104 PMCID: PMC9254894 DOI: 10.1053/j.semvascsurg.2022.05.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 11/16/2022]
Abstract
Peripheral artery disease (PAD), the pathophysiologic narrowing of arterial blood vessels of the lower leg due to atherosclerosis, is a highly prevalent disease that affects more than 6 million individuals 40 years and older in the United States, with sharp increases in prevalence with age. Morbidity and mortality rates in patients with PAD range from 30% to 70% during the 5- to 15-year period after diagnosis and PAD is associated with poor health outcomes and reduced functionality and quality of life. Despite advances in medical, endovascular, and open surgical techniques, there is striking variation in care among population subgroups defined by sex, race and ethnicity, and socioeconomic status, with concomitant differences in preoperative medication optimization, amputation risk, and overall health outcomes. We reviewed studies from 1995 to 2021 to provide a comprehensive analysis of the current impact of disparities on the treatment and management of PAD and offer action items that require strategic partnership with primary care providers, researchers, patients, and their communities. With new technologies and collaborative approaches, optimal management across all population subgroups is possible.
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Affiliation(s)
- Falen Demsas
- Geisel School of Medicine at Dartmouth, Hanover, NH
| | | | - Kate Telma
- Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Alyssa M Flores
- Department of Surgery, Division of Vascular Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Elsie Gyang Ross
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA; Center for Biomedical Informatics Research, Stanford University, Stanford, CA; Stanford Cardiovascular Institute, 780 Welch Road, CJ350, Palo Alto, CA 94304.
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Tan TW, Calhoun EA, Knapp SM, Lane AI, Marrero DG, Kwoh CK, Zhou W, Armstrong DG. Rates of Diabetes-Related Major Amputations Among Racial and Ethnic Minority Adults Following Medicaid Expansion Under the Patient Protection and Affordable Care Act. JAMA Netw Open 2022; 5:e223991. [PMID: 35323948 PMCID: PMC8948528 DOI: 10.1001/jamanetworkopen.2022.3991] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 02/06/2022] [Indexed: 12/14/2022] Open
Abstract
Importance It is not known whether implementation of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the outcomes among racial and ethnic minority adults at risk of diabetes-related major amputations. Objective To explore the association of early Medicaid expansion with outcomes of diabetic foot ulcerations (DFUs). Design, Setting, and Participants This cohort study included hospitalizations for DFUs among African American, Asian and Pacific Islander, American Indian or Alaska Native, and Hispanic adults as well as adults with another minority racial or ethnic identification aged 20 to 64 years. Data were collected from the State Inpatient Databases for 19 states and the District of Columbia for 2013 to the third quarter of 2015. The analysis was performed on December 4, 2019, and updated on November 9, 2021. Exposures States were categorized into early-adopter states (expansion by January 2014) and nonadopter states. Main Outcomes and Measures Poisson regression was performed to examine the associations of state type, time, and their combined association with the proportional changes of major amputation rate per year per 100 000 population. Results Among the 115 071 hospitalizations among racial and ethnic minority adults with DFUs (64% of sample aged 50 to 64 years; 35%, female; 61%, African American; 25%, Hispanic; 14%, other racial and ethnic minority group), there were 36 829 hospitalizations (32%) for Medicaid beneficiaries and 10 500 hospitalizations (9%) for uninsured patients. Hospitalizations increased 3% (95% CI, 1% to 5%) in early-adopter states and increased 8% (95% CI, 6% to 10%) in nonadopter states after expansion, a significant difference (P for interaction < .001). Although there was no change in the amputation rate (0.08%; 95% CI, -6% to 7%) in early-adopter states after expansion, there was a 9% (95% CI, 3% to 16%) increase in nonadopter states, a significant change (P = .04). For uninsured adults, the amputation rate decreased 33% (95% CI, 10% to 50%) in early-adopter states and did not change (12%; 95% CI, -10% to 38%) in nonadopter states after expansion, a significant difference (P = .006). There was no difference in the change of amputation rate among Medicaid beneficiaries between state types after expansion. Conclusions and Relevance This study found a relative improvement in the major amputation rate among African American, Hispanic, and other racial and ethnic minority adults in early-expansion states compared with nonexpansion states, which could be because of the recruitment of at-risk uninsured adults into the Medicaid program during the first 2 years of ACA implementation. Future study is required to evaluate the long-term association of Medicaid expansion and the rates of amputation.
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Affiliation(s)
- Tze-Woei Tan
- Department of Surgery, University of Arizona College of Medicine, Tucson
- Southwestern Academic Limb Salvage Alliance (SALSA), Los Angeles, California
| | - Elizabeth A. Calhoun
- Department of Population Health, University of Kansas Medical Center, Kansas City
| | - Shannon M. Knapp
- Statistics Consulting Lab, Bio5 Institute, University of Arizona, Tucson
| | - Adelina I. Lane
- Department of Surgery, University of Arizona College of Medicine, Tucson
| | - David G. Marrero
- Center for Border Health Disparities, University of Arizona Health Science, Tucson
| | - C. Kent Kwoh
- Department of Medicine, University of Arizona College of Medicine, Tucson
| | - Wei Zhou
- Department of Surgery, University of Arizona College of Medicine, Tucson
| | - David G. Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Los Angeles, California
- Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles
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Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
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12
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Sorour AA, Kirksey L, Laczynski DJ, Hoell NG, Bena J, Kalahasti V, Roselli EE, Smolock CJ, Lyden SP, Caputo FJ. Racial Disparities in Presentation and Short-Term Outcomes in Patients with Acute Type B Aortic Dissection. J Vasc Surg 2022; 75:1855-1863.e2. [PMID: 35074411 DOI: 10.1016/j.jvs.2022.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/03/2022] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Racial disparities in cardiovascular risk factors and disease outcomes are well documented. A knowledge gap exists on the role health maintenance plays in the development and outcomes of type B aortic dissection (TBAD). This study aims to evaluate the comparative presentation and short-term outcomes of patients with TBAD across race. METHODS In this single center retrospective study, TBAD patients admitted to the intensive care unit (ICU) were identified from 2015 to 2020. Patients self-identified as Black (N= 57) and White (N=123) were included. Groups were compared on variables including demographics, socioeconomic, pre-event health maintenance. Socioeconomic disadvantage was quantified based on The Area Deprivation Index (ADI). Management strategies included nonoperative and surgical repair. Outcomes were 30-day mortality, length of stay (LOS), and Acute Physiology and Chronic Health Evaluation (APACHE II) score. RESULTS The study included 180 consecutive patients with TBAD. TBAD included complicated (n= 42) and uncomplicated (n=138), of which (n=79) had high risk features. Blacks were younger than Whites (58.9 vs 67.6; p< 0.01), more likely to have end stage renal disease (ESRD) (8.8% vs 0.8%; p= 0.01) and to present with anemia (10.5% vs 2.4%; p=0.03). TBAD anatomic features and management were similar in both groups. Surgical intervention during hospitalization was 40% and 46% in Blacks and Whites, respectively (p= 0.4). Black patients were more likely to be on 3 or more hypertension agents, (42.2% vs 16.4%; p= 0.005) and less likely to be adherent to prescribed agents (27.1% vs 6.7%; p<0.001). Black patients had fewer primary care physician (PCP) visits prior to TBAD event (p= 0.03) and more Emergency Department (ED) utilization prior to TBAD, (57.9% vs 26.9% ;p < 0.001). Black patients had higher ADI scores, 86.0 ± 14.6 vs 64.4 ± 21.3 (p < 0.001). Median [IQR] APACHE II score was the same in both Blacks and Whites, 9[6, 12] and 9[7, 13] respectively (p=0.7). Hospital median LOS (days) was identical in both groups 7 [5, 13]. Readmission was 24.5% in Blacks vs 15.5% in Whites (p=0.16) with a 30-day mortality similar in Blacks 7.0% vs 5.7% Whites (p= 0.7). CONCLUSION Black patients present younger with similar dissection morphology, rate of anatomic high risk features and APACHE II scores. Fewer PCP visits, greater ED utilization, and higher ADI suggest lower health maintenance in Black patients. White patients with TBAD were also highly deprived of health maintenance compared to the national percentile, indicating that TBAD is a disease that affects vulnerable populations regardless of race.
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Affiliation(s)
- Ahmed A Sorour
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Aortic Center, Cleveland Clinic, Cleveland, Ohio.
| | - Levester Kirksey
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Aortic Center, Cleveland Clinic, Cleveland, Ohio; Walter W. Buckley Endowed Chair, Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH.
| | - David J Laczynski
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Aortic Center, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas G Hoell
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Aortic Center, Cleveland Clinic, Cleveland, Ohio
| | - James Bena
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Aortic Center, Cleveland Clinic, Cleveland, Ohio
| | - Vidyasagar Kalahasti
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christopher J Smolock
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Aortic Center, Cleveland Clinic, Cleveland, Ohio
| | - Sean P Lyden
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Aortic Center, Cleveland Clinic, Cleveland, Ohio
| | - Francis J Caputo
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Aortic Center, Cleveland Clinic, Cleveland, Ohio
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Gandjian M, Sareh S, Premji A, Ugarte R, Tran Z, Bowens N, Benharash P. Racial disparities in surgical management and outcomes of acute limb ischemia in the United States. Surg Open Sci 2021; 6:45-50. [PMID: 34632355 PMCID: PMC8487073 DOI: 10.1016/j.sopen.2021.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 08/22/2021] [Accepted: 08/27/2021] [Indexed: 12/04/2022] Open
Abstract
Background Although significant racial disparities in the surgical management of lower extremity critical limb threatening ischemia have been previously reported, data on disparities in lower extremity acute limb ischemia are lacking. Methods The 2012–2018 National Inpatient Sample was queried for all adult hospitalizations for acute limb ischemia (N = 225,180). Hospital-specific observed-to-expected rates of major lower extremity amputation were tabulated. Multivariable logistic and linear models were developed to assess the impact of race on amputation and revascularization. Results Nonwhite race was associated with significantly increased odds of overall (adjusted odds ratio: 1.16, 95% confidence interval 1.06–1.28) and primary (adjusted odds ratio: 1.34, 95% confidence interval 1.17–1.53) major amputation, decreased odds of revascularization (adjusted odds ratio 0.79, 95% confidence interval 0.73–0.85), but decreased in-hospital mortality (adjusted odds ratio: 0.86, 95% confidence interval 0.74–0.99). The nonwhite group incurred increased adjusted index hospitalization costs (β: +$4,810, 95% confidence interval 3,280-6,350), length of stay (β: + 1.09 days, 95% confidence interval 0.70–1.48), and nonhome discharge (adjusted odds ratio: 1.15, 95% confidence interval 1.06–1.26). Conclusion Significant racial disparities exist in the management of and outcomes of lower extremity acute limb ischemia despite correction for variations in hospital amputation practices and other relevant hospital and patient characteristics. Whether the etiology lies primarily in patient, institution, or healthcare provider–specific factors has not yet been determined. Further studies of race-based disparities in management and outcomes of acute limb ischemia are warranted to provide effective and equitable care to all.
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Affiliation(s)
- Matthew Gandjian
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA.,Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA
| | - Sohail Sareh
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA.,Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA
| | - Alykhan Premji
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Ramsey Ugarte
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Nina Bowens
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA
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Loehrer AP, Leech MM, Weiss JE, Markey C, Wengle E, Aarons J, Zuckerman S. Association of Cost Sharing With Delayed and Complicated Presentation of Acute Appendicitis or Diverticulitis. JAMA HEALTH FORUM 2021; 2:e212324. [PMID: 35977177 PMCID: PMC8796960 DOI: 10.1001/jamahealthforum.2021.2324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/01/2021] [Indexed: 01/17/2023] Open
Abstract
Question Does an association exist between high cost-sharing insurance plans and patient presentation with and surgical management of acute appendicitis or acute diverticulitis? Findings In this cohort study of 151 852 patients, higher patient cost sharing was associated with lower odds of presenting with early, uncomplicated disease, receiving optimal surgical care, and receiving minimally invasive surgery. Meaning Policymakers should be aware of the clinical and financial implications of patient health care behaviors associated with increased cost sharing. Importance Treatment delays are associated with increased morbidity and cost of disease, although the extent to which cost sharing influences timely presentation and management of acute surgical disease remains unknown. Given recent policy changes using cost sharing to modify health care behavior, this study examines the association of cost sharing with the health of the patient at presentation and with receipt of optimal or minimally invasive surgery. Objective To assess whether cost sharing is associated with the likelihood of early, uncomplicated patient presentation or with surgical management of 2 representative emergency general surgery diagnoses: acute appendicitis and acute diverticulitis. Design, Setting, and Participants This cohort study used Health Care Cost Institute claims from January 1, 2013, through December 31, 2017, to analyze data of commercially insured individuals hospitalized for acute appendicitis or diverticulitis. In total, 151 852 patients in the data set aged 18 to 64 years and presenting with acute appendicitis or diverticulitis were included as identified using the International Classification of Diseases, Ninth Revision and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Data were analyzed from January 2020 through February 2021. Exposures The primary exposure was patient total cost sharing incurred for the index hospitalization, defined as their summed deductible, copayments, and coinsurance. Main Outcomes and Measures The primary outcome was early, uncomplicated disease presentation. Secondary outcomes were receipt of optimal surgical care and minimally invasive surgery if undergoing an operation. Analyses were conducted with multivariable logistic regression models to adjust for patient characteristics and community-level socioeconomic and geographic factors. High cost sharing was defined as quartile 4 (>$3082), and low cost sharing as quartile 1 ($0-$502). Results Among 151 852 patients, 52.4% were men, and the total cost-sharing median was $1725 (interquartile range, $503-$3082). Higher cost sharing was associated with lower odds of early, uncomplicated disease presentation (odds ratio, 0.63; 95% CI, 0.61-0.65). Patients with higher cost sharing were less likely to receive optimal surgical care (odds ratio, 0.96; 95% CI, 0.93-0.99) or minimally invasive surgery (odds ratio, 0.89; 95% CI, 0.84-0.95). Conclusions and Relevance The findings of this cohort study suggest that, as policymakers debate the degree of cost sharing in public and private insurance plans, attention should be given to the clinical and financial implications associated with care delays.
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Affiliation(s)
- Andrew P. Loehrer
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Mary M. Leech
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Julie E. Weiss
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Chad Markey
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Association of Medicaid Expansion with In-Hospital Outcomes After Abdominal Aortic Aneurysm Repair. J Surg Res 2021; 266:201-212. [PMID: 34022654 DOI: 10.1016/j.jss.2021.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 02/08/2021] [Accepted: 02/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Multiple studies have shown improved outcomes and higher utilization of care with the increase of insurance coverage. This study aims to assess whether Medicaid expansion (ME) has changed the utilization and outcomes of abdominal aortic aneurysm (AAA) repair in the United States. DESIGN Retrospective observational study. MATERIALS Data of patients undergoing AAA repair in the Vascular Quality Initiative (2010-2017). METHODS Interrupted time-series (ITS) analysis was utilized to evaluate changes in annual trends of postoperative outcomes after elective AAA repair before and after 2014. We also assessed if these trend changes were significant by comparing the changes in states which adopted ME in 2014 versus nonexpansion states (NME), and conducting a difference-in-difference analysis. Primary outcomes included in-hospital mortality and adverse events (bowel and leg ischemia, cardiac, renal, respiratory, stroke and return to the OR). RESULTS A total of 19,143 procedures were included (Endovascular: 85.8% and open: 14.2%), of which 40.9% were performed in ME States. Compared to preexpansion trends (P1), there was a 2% annual increase in elective AAA repair in ME states (P1: -1.8% versus P2: +0.2%, P< 0.01) with no significant change in NME (P1: +0.3% versus P2: +0.2%, P = 0.97). Among elective cases, annual trends in the use of EVAR increased by 2% in ME states (95% confidence interval (CI) = -0.1, 4.1, P = 0.06), compared to a 3% decrease in NME States [95%CI = -5.8, -0.6, P = 0.01) (PMEversusNME < 0.01]. There was no association between ME and in-hospital mortality. Nonetheless, it was associated with a decrease in the annual trends of in-hospital complications (ME: -1.4% (-2.1,-0.8) versus NME: +0.2% (-0.2, +0.8), P < 0.01). CONCLUSIONS While no association between ME and increased survival was noted in states which adopted ME, there was a significant increase of elective AAA cases and EVAR utilization and a decrease in in-hospital complications in ME States.
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16
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Valdovinos EM, Niedzwiecki MJ, Guo J, Hsia RY. The association of Medicaid expansion and racial/ethnic inequities in access, treatment, and outcomes for patients with acute myocardial infarction. PLoS One 2020; 15:e0241785. [PMID: 33175899 PMCID: PMC7657521 DOI: 10.1371/journal.pone.0241785] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 10/20/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction After having an acute myocardial infarction (AMI), racial and ethnic minorities have less access to care, decreased rates of invasive treatments such as percutaneous coronary intervention (PCI), and worse outcomes compared with white patients. The objective of this study was to determine whether the Affordable Care Act’s expansion of Medicaid eligibility was associated with changes in racial disparities in access, treatments, and outcomes after AMI. Methods Quasi-experimental, difference-in-differences-in-differences analysis of non-Hispanic white and minority patients with acute myocardial infarction in California and Florida from 2010–2015, using linear regression models to estimate the difference-in-differences. This population-based sample included all Medicaid and uninsured patients ages 18–64 hospitalized with acute myocardial infarction in California, which expanded Medicaid through the Affordable Care Act beginning as early as July 2011 in certain counties, and Florida, which did not expand Medicaid. The main outcomes included rates of admission to hospitals capable of performing PCI, rates of transfer for patients who first presented to hospitals that did not perform PCI, rates of PCI during hospitalization and rates of early (within 48 hours of admission) PCI, rates of readmission to the hospital within 30 days, and rates of in-hospital mortality. Results A total of 55,991 hospital admissions met inclusion criteria, 32,540 of which were in California and 23,451 were in Florida. Among patients with AMI who initially presented to a non-PCI hospital, the likelihood of being transferred increased by 12 percentage points (95% CI 2 to 21) for minority patients relative to white patients after the Medicaid expansion. The likelihood of undergoing PCI increased by 3 percentage points (95% CI 0 to 5) for minority patients relative to white patients after the Medicaid expansion. We did not find an association between the Medicaid expansion and racial disparities in overall likelihood of admission to a PCI hospital, hospital readmissions, or in-hospital mortality. Conclusions The Medicaid expansion was associated with a decrease in racial disparities in transfers and rates of PCI after AMI. We did not find an association between the Medicaid expansion and admission to a PCI hospital, readmissions, and in-hospital mortality. Additional factors outside of insurance coverage likely continue to contribute to disparities in outcomes after AMI. These findings are crucial for policy makers seeking to reduce racial disparities in access, treatment and outcomes in AMI.
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Affiliation(s)
- Erica M Valdovinos
- Department of Emergency Medicine, Adventist Health Ukiah Valley, Ukiah, California, United States of America
| | - Matthew J Niedzwiecki
- Mathematica Policy Research.,Department of Emergency Medicine, University of California, San Francisco, California, United States of America.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, United States of America
| | - Joanna Guo
- Department of Emergency Medicine, University of California, San Francisco, California, United States of America
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco, California, United States of America.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, United States of America
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Notable Racial and Ethnic Disparities Persist in Lower Extremity Amputations for Critical Limb Ischemia and Infection. J Am Acad Orthop Surg 2020; 28:885-892. [PMID: 31934928 DOI: 10.5435/jaaos-d-19-00630] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The purpose of this study is to investigate the current disparities for major lower extremity amputation in patients with critical limb ischemia (CLI) and infection. METHODS A retrospective analysis of the National Surgical Quality Improvement Program's database for the years 2011 to 2017 was conducted. Multivariate models were used to isolate the effect of race and ethnicity on the likelihood of a below-knee or above-knee amputation (BKA and AKA, respectively) for CLI secondary to type 2 diabetes mellitus, atherosclerosis, peripheral vascular disease, chronic osteomyelitis, and deep soft-tissue infections. RESULTS For all diagnoses, blacks were 93.3%, and Hispanics were 61.9% more likely to undergo a BKA than white patients (P < 0.001). In addition, black patients had a 133.0% higher risk of an AKA than white patients (P < 0.001). Disparities were greatest with blacks undergoing surgery for CLI secondary to atherosclerosis (BKA odds ratio 2.093; AKA: odds ratio 2.625). Black patients also had an elevated risk of amputation secondary to diabetes, peripheral vascular disease, and deep soft-tissue infections (P < 0.001). DISCUSSION This nationally representative, cohort-based study demonstrates that notable racial and ethnic disparities for lower extremity amputations persist, with a higher proportion of black and Hispanic patients undergoing amputation compared with limb salvage procedures for atraumatic CLI and infection. LEVEL OF EVIDENCE Level III prognostic.
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Hurwitz M, Fuentes M. Healthcare Disparities in Dysvascular Lower Extremity Amputations. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00281-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Tan TW, Armstrong DG, Concha-Moore KC, Marrero DG, Zhou W, Calhoun E, Chang CY, Lo-Ciganic WH. Association between race/ethnicity and the risk of amputation of lower extremities among medicare beneficiaries with diabetic foot ulcers and diabetic foot infections. BMJ Open Diabetes Res Care 2020; 8:8/1/e001328. [PMID: 32843499 PMCID: PMC7449291 DOI: 10.1136/bmjdrc-2020-001328] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 07/14/2020] [Accepted: 07/23/2020] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION This study aimed to examine the association of race and ethnicity on the risk of lower extremity amputations among Medicare beneficiaries with diabetic foot ulcers (DFUs) and diabetic foot infections (DFIs). RESEARCH DESIGN AND METHODS A retrospective study included 2011-2015 data of a 5% sample of fee-for-service Medicare beneficiaries with a newly diagnosed DFU and/or DFI. The primary outcome was the time to the first major amputation episode after a DFU and/or DFI were identified using the diagnosis and procedure codes. We used multivariable Cox proportional hazards models to estimate the risk of time to the first major amputation across races, adjusting for sociodemographic and health status factors. Adjusted hazard ratios (aHRs) with a 95% CI were reported. RESULTS Among 92 929 Medicare beneficiaries newly diagnosed with DFUs and/or DFIs, 77% were whites, 14.3% African Americans (AAs), 3.3% Hispanics, 0.7% Native Americans (NAs), and 4.0% were other races. The incidence rates of major amputation were 0.02 person-years for NAs, 0.02 person-years for AAs, 0.01 person-years for Hispanics, 0.01 person-years for other races, and 0.01 person-years for whites (p<0.05). Multivariable analysis showed that AAs (aHR=1.9, 95% CI 1.7 to 2.2, p<0.0001) and NAs (aHR=1.8, 95% CI 1.3 to 2.6, p=0.001) were associated with an increased risk of major amputation compared with whites. Beneficiaries with DFUs and/or DFIs diagnosed by a podiatrist or primary care physician (aHR=0.7, 95% CI 0.6 to 0.8, p<0.0001, specialists as reference) or at an outpatient visit (aHR=0.3, 95% CI 0.3 to 0.3, p<0.0001, inpatient stay as reference) were associated with a decreased risk of major amputation. CONCLUSIONS Racial and ethnic disparities in the risk of lower extremity amputations appear to exist among fee-for-service Medicare beneficiaries with diabetic foot problems. AAs and NAs with DFUs and/or DFIs were associated with an increased risk of major amputations compared with white Medicare beneficiaries.
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Affiliation(s)
- Tze-Woei Tan
- University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | - David G Armstrong
- Surgery, University of Southern California, Los Angeles, California, USA
| | | | - David G Marrero
- University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | - Wei Zhou
- University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | | | - Ching-Yuan Chang
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida Health, Gainesville, Florida, USA
| | - Wei-Hsuan Lo-Ciganic
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida Health, Gainesville, Florida, USA
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Treatment of Acute Cholecystitis: Do Medicaid and Non-Medicaid Enrolled Patients Receive the Same Care? J Gastrointest Surg 2020; 24:939-948. [PMID: 31823324 DOI: 10.1007/s11605-019-04471-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 11/06/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Nationally, Medicaid enrollees with emergency surgical conditions experience worse outcomes overall when compared with privately insured patients. The goal of this study is to investigate disparities in the treatment of cholecystitis based on insurance type and to identify contributing factors. METHODS Adults with cholecystitis at a safety-net hospital in Central Massachusetts from 2017-2018 were included. Sociodemographic and clinical characteristics were compared based on Medicaid enrollment status (Medicare excluded). Univariate and multivariate analyses were used to compare the frequency of surgery, time to surgery (TTS), length of stay (LOS), and readmission rates between groups. RESULTS The sample (n = 203) included 69 Medicaid enrollees (34%), with a mean age of 44.4 years. Medicaid enrollees were younger (p = 0.0006), had lower levels of formal education (high school diploma attainment, p < 0.0001), were more likely to be unmarried (p < 0.0001), Non-White (p = 0.0012), and require an interpreter (p < 0.0001). Patients in both groups experienced similar rates of laparoscopic cholecystectomy, TTS, and LOS; however, Medicaid enrollees experienced more readmissions within 30 days of discharge (30.4% vs 17.9%, p < 0.001). CONCLUSION Despite anticipated population differences, the treatment of acute cholecystitis was similar between Medicaid and Non-Medicaid enrollees, with the exception of readmission. Further research is needed to identify patient, provider, and/or population factors driving this disparity.
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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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Hicks CW, Wang P, Bruhn WE, Abularrage CJ, Lum YW, Perler BA, Black JH, Makary MA. Race and socioeconomic differences associated with endovascular peripheral vascular interventions for newly diagnosed claudication. J Vasc Surg 2020; 72:611-621.e5. [PMID: 31902593 DOI: 10.1016/j.jvs.2019.10.075] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 10/14/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite guidelines cautioning against the use of endovascular peripheral vascular interventions (PVI) for claudication, more than 1.3 million PVI procedures are performed annually in the United States. We aimed to describe national rates of PVI for claudication, and identify patient and county-level risk factors associated with a high rate of PVI. METHODS We used the Medicare claims database to identify all Medicare beneficiaries with a new diagnosis of claudication between January 2015 and June 2017. A hierarchical logistic regression model accounting for patient age, sex, comorbidities; county region and setting; and a patient race-county median income interaction was used to assess the associations of race and income with a high PVI rate. RESULTS We identified 1,201,234 patients with a new diagnosis of claudication for analysis. Of these, 15,227 (1.27%) underwent a PVI. Based on hierarchical logistic regression accounting for patient and county-level factors, black patients residing in low-income counties had a significantly higher odds of undergoing PVI than their white counterparts (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.20-1.40), whereas the odds of PVI for black versus white patients was similar in high-income counties (OR, 1.06; 95% CI, 0.99-1.14). PVI rates were higher for low versus high-income counties in both the black (OR, 1.46; 95% CI, 1.31-1.64) and white (OR, 1.19; 95% CI, 1.12-1.27) groups. There were no significant associations of Hispanic, Asian, North American native, or other races with PVI in either low- or high-income counties after risk adjustment (all P ≥ .09). CONCLUSIONS In the Medicare population, the mean rate of PVI of 12.7 per 1000 claudication patients varies significantly based on race and income. Our data suggest there are racial and socioeconomic differences in the treatment of claudication across the United States.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Peiqi Wang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - William E Bruhn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Ying W Lum
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Bruce A Perler
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md; Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
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Perez NP, Pernat CA, Chang DC. Surgical Disparities: Beyond Non-Modifiable Patient Factors. Health Serv Res 2020. [DOI: 10.1007/978-3-030-28357-5_5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Jelani QUA, Jhamnani S, Spatz ES, Spertus J, Smolderen KG, Wang J, Desai NR, Jones P, Gosch K, Shah S, Attaran R, Mena-Hurtado C. Financial barriers in accessing medical care for peripheral artery disease are associated with delay of presentation and adverse health status outcomes in the United States. Vasc Med 2019; 25:13-24. [PMID: 31603393 DOI: 10.1177/1358863x19872542] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient-reported difficulties in affording health care and their association with health status outcomes in peripheral artery disease (PAD) have never been studied. We sought to determine whether financial barriers affected PAD symptoms at presentation, treatment patterns, and patient-reported health status in the year following presentation. A total of 797 United States (US) patients with PAD were identified from the Patient-centered Outcomes Related to TReatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) study, a prospective, multicenter registry of patients presenting to vascular specialty clinics with PAD. Financial barriers were defined as a composite of no insurance and underinsurance. Disease-specific health status was measured by Peripheral Artery Questionnaire (PAQ) and general health-related quality of life was measured by EuroQol 5 (EQ5D) dimensions at presentation and at 3, 6, and 12 months of follow-up. Among 797 US patients, 21% (n = 165) of patients reported financial barriers. Patients with financial barriers presented at an earlier age (64 ± 9.5 vs 70 ± 9.4 years), with longer duration of symptoms (59% vs 49%) (all p ⩽ 0.05), were more depressed and had higher levels of perceived stress and anxiety. After multivariable adjustment, health status was worse at presentation in patients with financial barriers (PAQ: -7.0 [-10.7, -3.4]; p < 0.001 and EQ5D: -9.2 [-12.74, -5.8]; p < 0.001) as well as through 12 months of follow-up (PAQ: -8.4 [-13.0, -3.8]; p < 0.001 and EQ5D: -9.7 [-13.2, -6.2]; p < 0.001). In conclusion, financial barriers are associated with later presentation as well as poorer health status at presentation and at 12 months. ClinicalTrials.gov Identifier: NCT01419080.
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Affiliation(s)
- Qurat-Ul-Ain Jelani
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Sunny Jhamnani
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Erica S Spatz
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - John Spertus
- Department of Statistics, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,Biomedical & Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Kim G Smolderen
- Department of Statistics, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,Biomedical & Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Jingyan Wang
- Department of Statistics, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Nihar R Desai
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Philip Jones
- Department of Statistics, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Kensey Gosch
- Department of Statistics, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Samit Shah
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Robert Attaran
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Department of Medicine, Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA
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Impact of Medicaid Expansion of the Affordable Care on the Outcomes of Lower Extremity Bypass for Patients With Peripheral Artery Disease in the Vascular Quality Initiative Database. Ann Surg 2019; 270:647-655. [DOI: 10.1097/sla.0000000000003521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Loehrer AP, Chang DC, Scott JW, Hutter MM, Patel VI, Lee JE, Sommers BD. Association of the Affordable Care Act Medicaid Expansion With Access to and Quality of Care for Surgical Conditions. JAMA Surg 2019; 153:e175568. [PMID: 29365029 DOI: 10.1001/jamasurg.2017.5568] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Andrew P. Loehrer
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - David C. Chang
- Department of Surgery, Massachusetts General Hospital, Boston
| | - John W. Scott
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Virendra I. Patel
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Jeffrey E. Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Benjamin D. Sommers
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts,Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Builyte IU, Baltrunas T, Butkute E, Srinanthalogen R, Skrebunas A, Urbonavicius S, Rucinskas K. Peripheral artery disease patients are poorly aware of their disease. SCAND CARDIOVASC J 2019; 53:373-378. [DOI: 10.1080/14017431.2019.1645350] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
| | - Tomas Baltrunas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre of Reconstructive Vascular and Endovascular Surgery, Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania
| | - Egle Butkute
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Reshaabi Srinanthalogen
- Department of Vascular Surgery, Cardiovascular Research Unit, Hospitalsenhed Midt, Viborg, Denmark
| | - Arminas Skrebunas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre of Reconstructive Vascular and Endovascular Surgery, Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania
| | - Sigitas Urbonavicius
- Department of Vascular Surgery, Cardiovascular Research Unit, Hospitalsenhed Midt, Viborg, Denmark
| | - Kestutis Rucinskas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre of Heart and Chest Surgery, Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania
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Tortolero-Luna G, Torres-Cintrón CR, Alvarado-Ortiz M, Ortiz-Ortiz KJ, Zavala-Zegarra DE, Mora-Piñero E. Incidence of thyroid cancer in Puerto Rico and the US by racial/ethnic group, 2011-2015. BMC Cancer 2019; 19:637. [PMID: 31253133 PMCID: PMC6599344 DOI: 10.1186/s12885-019-5854-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 06/19/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Puerto Rico has the highest incidence rate of thyroid cancer (TC) in the Americas and the third highest rate worldwide. The purpose of this study was to compare the burden of TC between the population of PR and United States (US) non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB), and US Hispanics (USH) during the period 2011-2015. METHODS TC data for the period 2011-2015 was obtained from the Puerto Rico Central Cancer Registry (PRCCR) and the Surveillance Epidemiology and Ends Results Program (SEER) 18 Registries Research Data. TC was categorized in: papillary carcinoma (PTC), and other TC histologic types. Data was analyzed by sex, age groups, and histologic type. Racial/ethnic differences by sex, age, and histologic types were assessed using the Standardized Rate Ratio (SRR) and its 95% CI. RESULTS During the period 2011-2015 there were 5175 and 65,528 cases of TC diagnosed in PR and the US, respectively. The overall age-adjusted incidence rate of PTC was almost two-fold higher in PR than in the US (25.8/100,000 vs. 12.9/100,000). Among PR women, the incidence rate of PTC was 40.0/100,000 compared to 19.4/100,000 in US. PR women had 83% increased risk of being diagnosed with PTC than NHW women, a 2.25-fold increased risk than USH, and 3.45-fold increased risk than NHB women. For men, PR had 34% increased risk of being diagnosed with PTC than NHW men, 2.2-fold increased risk than USH men, and 3.2-fold higher risk than in NHB men. CONCLUSION Further research is needed to understand this disparity in the island. This research should address the extent of overdiagnosis in PR, the role of health insurance status and insurance type, characteristics of the healthcare delivery system as well as the role of patient and environmental factors.
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Affiliation(s)
- Guillermo Tortolero-Luna
- Puerto Rico Central Cancer Registry, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
- Division of Cancer Control and Population Sciences, University of Puerto Rico, Comprehensive Cancer Center, PO Box 70344, San Juan, PR 00936-8344 Puerto Rico
| | - Carlos R. Torres-Cintrón
- Puerto Rico Central Cancer Registry, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
| | - Mariela Alvarado-Ortiz
- Puerto Rico Central Cancer Registry, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
- Department of Social Sciences, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
| | - Karen J. Ortiz-Ortiz
- Puerto Rico Central Cancer Registry, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
- Division of Cancer Control and Population Sciences, University of Puerto Rico, Comprehensive Cancer Center, PO Box 70344, San Juan, PR 00936-8344 Puerto Rico
| | - Diego E. Zavala-Zegarra
- Puerto Rico Central Cancer Registry, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
| | - Edna Mora-Piñero
- Division of Cancer Control and Population Sciences, University of Puerto Rico, Comprehensive Cancer Center, PO Box 70344, San Juan, PR 00936-8344 Puerto Rico
- Department of Surgery, School of Medicine, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
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Harris CM, Albaeni A, Thorpe RJ, Norris KC, Abougergi MS. Racial factors and inpatient outcomes among patients with diabetes hospitalized with foot ulcers and foot infections, 2003-2014. PLoS One 2019; 14:e0216832. [PMID: 31141534 PMCID: PMC6541346 DOI: 10.1371/journal.pone.0216832] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 04/29/2019] [Indexed: 11/18/2022] Open
Abstract
Background In patients with diabetes, foot amputations among Black patients have been historically higher compared with White patients. Using the National Inpatient Sample database, we sought to determine if disparities in foot amputations and resource utilization have improved over time. We hypothesized there would be improvements and reduced differences in foot amputations between the two races as quality of care and access to healthcare has improved. Methods and findings Patients over 18 years old with a principal diagnosis of diabetic foot complications and secondary diagnosis of Diabetes Mellitus were selected. We compared the primary outcome of foot amputations between Black and White patients. Adjusted rates, odds ratios (aOR) and trends of foot amputations among Black and White patients were studied. Healthcare utilization was measured via length of hospital stay (LOS). Of 262,924 patients, 18% were Black. Following adjustment for confounders, major foot amputations decreased among Whites (1.5% in 2003 to 1.1% in 2014) and Blacks (2.1% in 2003 to 0.9% in 2014). On pooled analysis, Black patients had higher adjusted odds of major foot amputations in 2003–2004 [aOR 1.7; (1.16–2.57), p<0.01]. Disparities in major foot amputations disappeared in 2013–2014 [aOR: 0.92 (0.58–1.44), p = 0.70]. Black patients had declining but persistently longer LOS (adjusted mean difference (aMD): 1.1 days (0.52–1.6) p<0.01 in 2003–2004 and 0.46 days (0.18–0.73) p<0.01 in 2013–2014). The main limitation of the study was that the NIS uses ICD-9 and ICD-10 CM codes, and hence prone to incorrect or missing codes. Conclusions Major foot amputations declined among Black and White patients hospitalized with Diabetic foot complications between 2003 and 2014. The observed difference for amputations in 2003–2004 was absent by 2013–2014. Future research to determine specific contributors for this reduction in health disparities is needed for ongoing improvements and sustainability.
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Affiliation(s)
- Ché Matthew Harris
- Department of General Internal Medicine, Johns Hopkins School of Medicine, Division of Hospital Medicine Johns Hopkins Bayview Medical Center, Baltimore, Maryland, United States of America
- * E-mail:
| | - Aiham Albaeni
- Department of Medicine, University of Central Florida, Ocala, Florida, United States of America
| | - Roland J. Thorpe
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Keith C. Norris
- Department of Internal Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
| | - Marwan S. Abougergi
- Department of Internal Medicine, Division of Gastroenterology, University of South Carolina School of Medicine, Columbia, South Carolina United States of America
- Catalyst Medical Consulting, Simpsonville, SC, United States of America
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Yin C, Sing DC, Curry EJ, Abdul-Rassoul H, Galvin JW, Eichinger JK, Li X. The Effect of Race on Early Perioperative Outcomes After Shoulder Arthroplasty: A Propensity Score Matched Analysis. Orthopedics 2019; 42:95-102. [PMID: 30810757 DOI: 10.3928/01477447-20190221-01] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 02/04/2019] [Indexed: 02/03/2023]
Abstract
There is a paucity of data on how racial disparities may affect early outcomes following shoulder arthroplasty. The purpose of this study was to evaluate differences in 30-day complications and readmission rates after shoulder arthroplasty based on race. White and black patients who underwent hemiarthroplasty, anatomic or reverse total shoulder arthroplasty (Current Procedural Terminology codes 23470 and 23472) between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Black patients were propensity score matched 1:4 based on preoperative demographics and comorbidities to white patients. Multivariable analysis was performed to assess postoperative complications based on race. Of the 12,663 patients with shoulder arthroplasty identified, 10,717 (84.6%) were white and 559 (4.4%) were black. Overall, 557 black patients were matched to 2228 white patients, for a total cohort of 2785 patients (mean age, 63.9±11.7 years; female, 61.0%). Surgical indications were similar between black and white patients. The 2 races had similar rates of overall complications, major complications, minor complications, readmissions, and discharge to facility. Mortality was significantly higher among black patients compared with white patients (0.6% vs 0.05%; P=.033). Black patients also experienced longer operative time (mean, 126.4 vs 112.5 minutes; P<.001) and length of stay (mean, 2.4 vs 2.1 days; P<.001). There was a significant disparity with underutilization of shoulder arthroplasty for black patients in the American College of Surgeons National Surgical Quality Improvement Program database. Black and white patients undergoing shoulder arthroplasty experienced similar rates of 30-day complications, readmissions, and discharge to facility. However, black patients experienced greater operative time, total length of stay, and mortality compared with white patients. [Orthopedics. 2019; 42(2):95-102.].
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Dua A, Rothenberg K, Srivastava G, Brown K, Lewis B, Rossi P, Seabrook G, Malinowski M, Wohlauer M, Lee CJ. Evolving Trends in Insurance Coverage of Vascular Surgery Patients in Academic Practice. Ann Vasc Surg 2018; 57:170-173. [PMID: 30500649 DOI: 10.1016/j.avsg.2018.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/23/2018] [Accepted: 09/20/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Insurance coverage of vascular surgery patients may differ from patients with less chronic surgical pathologies. The goal of this study is to identify trends in insurance status of vascular surgery patients over the last 10 years at a busy academic center. METHODS All consecutive patient visits for a vascular procedure from 2006 to 2016 were retrospectively reviewed from a prospectively collected institutional database. Data points included insurance status, procedures performed, and date of admission. The insurance status was categorized as Medicare, Medicaid, and uninsured. Samples were divided between 2006-2009 and 2011-2016 for comparison. Unpaired t-test, chi-squared test, and regression analysis were used to determine significant trends over the study period. RESULTS From 2006 to 2016, 6,007 vascular surgery procedures were performed. Procedure volume increased significantly from 1,309 to 4,698 between the 2 timeframes (P < 0.05), whereas the percentage of Medicaid and Medicare patients trended upward but did not achieve significance. There was a significant decrease in the percentage of uninsured patients between the cohorts (5.65% vs. 2.96%, P < 0.05). In 2012, 10.14% of patients were uninsured compared with 2.56% in 2016 (P < 0.05). CONCLUSIONS Insurance status affects access to care and subsequent outcomes. In our busy academic center, insurance coverage for vascular surgery has significantly increased over the past decade. The number of Medicaid and Medicare patients has slowly increased, but a significant and continuing decline in uninsured patients was observed. Implementation of the Affordable Care Act during this time period may have played a role in providing coverage for patient needing vascular surgery.
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Affiliation(s)
- Anahita Dua
- Division of Vascular Surgery, Stanford Health Care, Stanford, CA; Medical College of Wisconsin, Brookfield, WI
| | - Kara Rothenberg
- Division of Vascular Surgery, Stanford Health Care, Stanford, CA
| | | | | | - Brian Lewis
- Medical College of Wisconsin, Brookfield, WI
| | - Peter Rossi
- Medical College of Wisconsin, Brookfield, WI
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Girijala RL, Bush RL. Review of Socioeconomic Disparities in Lower Extremity Amputations: A Continuing Healthcare Problem in the United States. Cureus 2018; 10:e3418. [PMID: 30542632 PMCID: PMC6284870 DOI: 10.7759/cureus.3418] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Lower extremity amputation is one of the most unfortunate, yet preventable, consequences of uncontrolled lower limb ischemia occurring secondary to diabetes mellitus or peripheral arterial disease. In the United States, racial and socioeconomic disparities are associated with significant differences seen in the incidence and type or level of lower extremity amputation among patients. Due to shifting demographics and the uncertain state of healthcare coverage, lower extremity amputation rates are only projected to increase in the future. Given the potential societal and individual costs associated with the loss of a limb, this review seeks to summarize the recent findings on disparities in the identification, treatments offered, and outcomes of lower limb ischemia in order to elucidate potential interventions at the practitioner and policy levels.
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Affiliation(s)
| | - Ruth L Bush
- Surgery, University of Houston College of Medicine, Houston, USA
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Stapleton SM, Bababekov YJ, Perez NP, Fong ZV, Hashimoto DA, Lillemoe KD, Watkins MT, Chang DC. Variation in Amputation Risk for Black Patients: Uncovering Potential Sources of Bias and Opportunities for Intervention. J Am Coll Surg 2018; 226:641-649.e1. [DOI: 10.1016/j.jamcollsurg.2017.12.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/19/2017] [Indexed: 10/18/2022]
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Noyes AM, Abbott JD, Gosch K, Smolderen K, Spertus JA, Hyder O, Soukas P, Shishehbor MH, Aronow HD. Association between health status and sociodemographic, clinical and treatment disparities in the Patient-centered Outcomes Related to TReatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) registry. Vasc Med 2018; 23:32-38. [DOI: 10.1177/1358863x17747047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients with peripheral artery disease (PAD) and intermittent claudication (IC) have impaired functional status and quality of life. However, little is known about which factors are associated with poorer health status at the time of initial presentation for PAD specialty care. Characterization of such features might provide insight into disparities that impact health status in this population. A total of 1258 patients from the United States, the Netherlands and Australia with new or worsened IC were enrolled at their first PAD specialty care visit between June 2011 and December 2015. The mean Peripheral Artery Questionnaire (PAQ) Summary Score (range 0–100), a disease-specific health status measure, was 49.2 ± 21.9. Hierarchical, multivariable linear regression was used to relate patient characteristics to baseline PAQ. Patient characteristics independently associated with poorer health status were age ( p < 0.001), female sex ( p < 0.001), not being married ( p = 0.02), economic burden (moderate/severe vs none, moderate/severe vs some; p = 0.03), difficulty getting care (moderate/severe vs none, moderate/severe vs some; p < 0.001), chronic lung disease ( p = 0.02), back pain ( p < 0.001), bilateral vs unilateral PAD ( p = 0.02), intermittent claudication severity (moderate vs mild, severe vs mild, p < 0.001), and lack of prior participation in an exercise program ( p = 0.005). Disparities in both vascular and non-vascular factors were associated with patients’ health status at the time of presentation and should be addressed by all who care for patients with vascular disease.
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Affiliation(s)
- Adam M Noyes
- Warren Alpert Medical School at Brown University, Lifespan Cardiovascular Institute, Providence, RI, USA
| | - J Dawn Abbott
- Warren Alpert Medical School at Brown University, Lifespan Cardiovascular Institute, Providence, RI, USA
| | - Kensey Gosch
- Mid America Heart Institute of Saint Luke’s Hospital and the University of Missouri–Kansas City, Kansas City, MO, USA
| | - Kim Smolderen
- Mid America Heart Institute of Saint Luke’s Hospital and the University of Missouri–Kansas City, Kansas City, MO, USA
| | - John A Spertus
- Mid America Heart Institute of Saint Luke’s Hospital and the University of Missouri–Kansas City, Kansas City, MO, USA
| | - Omar Hyder
- Warren Alpert Medical School at Brown University, Lifespan Cardiovascular Institute, Providence, RI, USA
| | - Peter Soukas
- Warren Alpert Medical School at Brown University, Lifespan Cardiovascular Institute, Providence, RI, USA
| | - Mehdi H Shishehbor
- Case Western Reserve University School of Medicine, Harrington Heart & Vascular Institute, University Hospitals, Cleveland, OH, USA
| | - Herbert D Aronow
- Warren Alpert Medical School at Brown University, Lifespan Cardiovascular Institute, Providence, RI, USA
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Arya S, Binney Z, Khakharia A, Brewster LP, Goodney P, Patzer R, Hockenberry J, Wilson PWF. Race and Socioeconomic Status Independently Affect Risk of Major Amputation in Peripheral Artery Disease. J Am Heart Assoc 2018; 7:JAHA.117.007425. [PMID: 29330260 PMCID: PMC5850162 DOI: 10.1161/jaha.117.007425] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background Black race has been shown to be a risk factor for amputation in peripheral artery disease (PAD); however, race has been argued to be a marker for socioeconomic status (SES) rather than true disparity. The aim of this study is to study the impact of race and SES on amputation risk in PAD patients. Methods and Results Patients with incident PAD in the national Veterans Affairs Corporate Data Warehouse were identified from 2003 to 2014 (N=155 647). The exposures were race and SES (measured by median income in residential ZIP codes). The outcome was incident major amputation. Black veterans were significantly more likely to live in low‐SES neighborhoods and to present with advanced PAD. Black patients had a higher amputation risk in each SES stratum compared with white patients. In Cox models (adjusting for covariates), black race was associated with a 37% higher amputation risk compared with white race (hazard ratio: 1.37; 95% confidence interval, 1.30–1.45), whereas low SES was independently predictive of increased risk of amputation (hazard ratio: 1.12; 95% confidence interval, 1.06–1.17) and showed no evidence of interaction with race. In predicted amputation risk analysis, black race and low SES continued to be significant risk factors for amputation regardless of PAD presentation. Conclusions Black race significantly increases the risk of amputation within the same SES stratum compared with white race and has an independent effect on limb loss after controlling for comorbidities, severity of PAD at presentation, and use of medications.
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Affiliation(s)
- Shipra Arya
- Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA .,VA Palo Alto Health Care system, Palo Alto, CA
| | - Zachary Binney
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Anjali Khakharia
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Luke P Brewster
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA.,Surgical Service Line, Atlanta VA Medical Center, Decatur, GA
| | - Phil Goodney
- Section of Vascular Surgery Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Rachel Patzer
- Division of Transplant Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA.,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Jason Hockenberry
- Department of Health Policy, Emory University Rollins School of Public Health, Atlanta, GA
| | - Peter W F Wilson
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA.,Epidemiology and Genomic Medicine, Atlanta VA Medical Center, Decatur, GA
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Loehrer AP, Murthy SS, Song Z, Lubitz CC, James BC. Association of Insurance Expansion With Surgical Management of Thyroid Cancer. JAMA Surg 2017; 152:734-740. [PMID: 28384780 DOI: 10.1001/jamasurg.2017.0461] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Importance To our knowledge, thyroid cancer incidence is increasing faster than any other cancer type and is currently the fifth most common cancer among women. While this rise is likely multifactorial, there has been scarce consideration of the effect of insurance statuses on the treatment of thyroid cancer. Objective We evaluate the association of insurance expansion with thyroid cancer treatment using the 2006 Massachusetts health reform, which serves as a unique natural experiment. Design, Setting, and Participants We used the Agency for Healthcare Research and Quality State Inpatient Databases to identify patients with government-subsidized or self-pay insurance or private insurance who were admitted to a hospital with thyroid cancer and underwent a thyroidectomy between 2001 and 2011 in Massachusetts (n = 8534) and 3 control states (n = 48 047). Difference-in-differences models were used to evaluate an association between the 2006 Massachusetts health care reform and thyroid cancer treatment, and participants were controlled for age, sex, comorbidities, and secular trends. Main Outcomes and Measures Change in the thyroidectomy rate for thyroid cancer treatment was the primary outcome evaluated. Results The Massachusetts cohort consisted of 6443 women (75.5%) and 2091 men (24.5%), of whom 6388 (79.6%) were white, 391 (4.9%) were black, 527 (6.6%) were Hispanic, 424 (5.3%) were Asian/Pacific Islander, 63 (0.8%) were Native American, and 228 (2.8%) were other. The participants from control states included 36 818 women (76.6%) and 11 229 men (23.4%), of whom 30 432 (65.5%) were white, 3818 (8.2%) were black, 6462 (13.9%) were Hispanic, 2591 (5.6%) were Asian/Pacific Islander, 211 (0.5%) were Native American, and 2947 (6.3%) were other. Before the 2006 Massachusetts insurance expansion, patients with government-subsidized or self-pay insurance had lower thyroidectomy rates for thyroid cancer in Massachusetts and the control states compared with patients with private insurance. The Massachusetts insurance expansion was associated with a 26% increased rate of undergoing a thyroidectomy (incident rate ratio, 1.26; 95% CI, 1.04-1.52; P = .02) and a 22% increased rate of neck dissection (incident rate ratio, 1.22; 95% CI, 1.07-1.37; P = .002) for treating cancer compared with control states. Conclusions and Relevance The 2006 Massachusetts health reform, which is a model for the Affordable Care Act, was associated with a 26% increased rate of thyroidectomy for treating thyroid cancer. Our study suggests that insurance expansion may be associated with increased access to the surgical management of thyroid cancer. Further studies need to be conducted to evaluate the effect of healthcare expansion at a national level.
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Affiliation(s)
| | - Shilpa S Murthy
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Zirui Song
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Carrie C Lubitz
- Department of Surgery, Massachusetts General Hospital, Boston
| | - Benjamin C James
- Department of Surgery, Indiana University School of Medicine, Indianapolis
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Schonberger RB, Dai F, Brandt C, Burg MM. The effect of race on postsurgical ambulatory medical follow-up among United States Veterans. J Clin Anesth 2017; 40:55-61. [PMID: 28625448 PMCID: PMC5490668 DOI: 10.1016/j.jclinane.2016.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 10/14/2016] [Accepted: 11/03/2016] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE To investigate the association between self-identified black or African American race and the presence of ambulatory internal medicine follow-up in the year after surgery. Our hypothesis was that among US Veterans who presented for surgery, black or African American race would be associated with a decreased likelihood to receive ambulatory internal medicine follow-up in the year after surgery. DESIGN Retrospective observational. SETTING All US Veterans Affairs hospitals. PATIENTS A total of 236,200 Veterans undergoing surgery between 2006 and 2011 who were discharged within 10 days of surgery and survived the full 1-year exposure period. INTERVENTIONS None. MEASUREMENTS Attendance at an internal medicine follow-up appointment within 1 year after surgery. MAIN RESULTS After controlling for year of surgery, age, age ≥65 years, sex, Hispanic ethnicity, and number of inpatient days, black or African American patients were 11% more likely to lack internal medicine follow-up after surgery (adjusted odds ratio, 1.11; 95% confidence interval, 1.06-1.16). When accounting for geographic region, this difference remained significant at the Bonferoni-corrected P < .007 level only in the Midwest United States where black or African American patients were 28% more likely to lack medical follow-up in the year after surgery (odds ratio, 1.28; 95% confidence interval, 1.16-1.42; P < .0001). CONCLUSIONS The disparity in ambulatory medical follow-up following surgery among black or African American vs nonblack or non-African American Veterans in the Midwest region deserves further study and may lead to important quality improvement initiatives aimed specifically at this population.
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Affiliation(s)
- Robert B Schonberger
- Department of Anesthesiology, Yale School of Medicine, 333 Cedar St, TMP-3, New Haven, CT 06520.
| | - Feng Dai
- Department of Anesthesiology, Yale School of Medicine, 333 Cedar St, TMP-3, New Haven, CT 06520; Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT 06520.
| | - Cynthia Brandt
- Department of Anesthesiology, Yale School of Medicine, 333 Cedar St, TMP-3, New Haven, CT 06520; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT 06516; VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516.
| | - Matthew M Burg
- Department of Anesthesiology, Yale School of Medicine, 333 Cedar St, TMP-3, New Haven, CT 06520; Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06520.
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Armenia SJ, Pentakota SR, Merchant AM. Socioeconomic factors and mortality in emergency general surgery: trends over a 20-year period. J Surg Res 2017; 212:178-186. [PMID: 28550905 DOI: 10.1016/j.jss.2017.01.015] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 11/26/2016] [Accepted: 01/18/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Socioeconomic factors such as race, insurance, and income quartiles have been identified as independent risk factors in emergency general surgery (EGS), but this impact has not been studied over time. We sought to identify trends in disparities in EGS-related operative mortality over a 20-y period. METHODS The National Inpatient Sample was used to identify patient encounters coded for EGS in 1993, 2003, and 2013. Logistic regression models were used to examine the adjusted relationship between race, primary payer status, and median income quartiles and in-hospital mortality after adjusting for patients' age, gender, Elixhauser comorbidity score, and hospital region, size, and location-cum-teaching status. RESULTS We identified 391,040 patient encounters. In 1993, Black race was associated with higher odds of in-hospital mortality (odds ratio [95% confidence interval]: 1.35 [1.20-1.53]) than White race, although this difference dissipated in subsequent years. Medicare, Medicaid, and underinsured patients had a higher odds of mortality than those with private insurance for the entire 20-y period; only the disparity in the underinsured decreased over time (1993, 1.63 [1.35-1.98]; 2013, 1.41 [1.20-1.67]). In 2003 (1.23 [1.10-1.38]) and 2013 (1.23 [1.11-1.37]), patients from the lowest income quartile were more likely to die after EGS than patients from the highest income quartile. CONCLUSIONS Socioeconomic disparities in EGS-related operative morality followed inconsistent trends. Over time, while gaps in in-hospital mortality among Blacks and Whites have narrowed, disparities among patients belonging to lowest income quartile have worsened. Medicare and Medicaid beneficiaries continued to experience higher odds of in-hospital mortality relative to those with private insurance.
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Affiliation(s)
- Sarah J Armenia
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Sri Ram Pentakota
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Aziz M Merchant
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.
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Abstract
BACKGROUND Insurance impacts access to therapeutic options, yet little is known about how healthcare reform might change the pattern of surgical admissions. OBJECTIVE We compared rates of emergent admissions and outcomes after colectomy before and after reform in Massachusetts with a nationwide control group. DESIGN This study is a retrospective cohort analysis in a natural experiment. Prereform was defined as hospital discharge from 2002 through the second quarter of 2006 and postreform from the third quarter of 2006 through 2012. Categorical variables were compared by χ. Piecewise functions were used to test the effect of healthcare reform on the rate of emergent surgeries. SETTINGS The study included acute care hospitals in the Massachusetts Healthcare Cost and Utilization Project State Inpatient Database (2002-2012) and the Nationwide Inpatient Sample (2002-2011). PATIENTS Patients aged 18 to 64 years with public or no insurance who underwent inpatient colectomy (via International Classification of Diseases, Ninth Revision, Clinical Modification procedural code) were included and patients with Medicare were excluded. INTERVENTION Massachusetts health care reform was the study intervention. MAIN OUTCOME MEASURES We measured the rate of emergent colectomy, complications, and mortality. RESULTS The unadjusted rate of emergent colectomies was lower in Massachusetts after reform but did not change nationally over the same time period. For emergent surgeries in Massachusetts, a piecewise model with an inflection point (peak) in the third quarter of 2006, coinciding with implementation of healthcare reform in Massachusetts, had a lower mean squared error than a linear model. In comparison, the national rate of emergent surgeries demonstrated no change in pattern. Postreform, length of stay decreased by 1 day in Massachusetts; however, there were no significant improvements in other outcomes. LIMITATIONS The study was limited by its retrospective design and unadjusted analysis. CONCLUSIONS There was a unique and sustained decline in the rate of emergent colon resection among publically insured and uninsured patients after 2006 in Massachusetts, in contradistinction to the national pattern, suggesting improved access to care associated with health insurance expansion. The reasons for lack of improvement in outcomes are multifactorial.
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Loehrer AP, Song Z, Haynes AB, Chang DC, Hutter MM, Mullen JT. Impact of Health Insurance Expansion on the Treatment of Colorectal Cancer. J Clin Oncol 2016; 34:4110-4115. [PMID: 27863191 DOI: 10.1200/jco.2016.68.5701] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Purpose Colorectal cancer is the third most common cancer and the third leading cause of cancer deaths in the United States. Lack of insurance coverage has been associated with more advanced disease at presentation, more emergent admissions at time of colectomy, and lower survival relative to privately insured patients. The 2006 Massachusetts health care reform serves as a unique natural experiment to assess the impact of insurance expansion on colorectal cancer care. Methods We used the Hospital Cost and Utilization Project State Inpatient Databases to identify patients with colorectal cancer with government-subsidized or self-pay (GSSP) or private insurance admitted to a hospital between 2001 and 2011 in Massachusetts (n = 17,499) and three control states (n = 144,253). Difference-in-differences models assessed the impact of the 2006 Massachusetts coverage expansion on resection of colorectal cancer, controlling for confounding factors and secular trends. Results Before the 2006 Massachusetts reform, government-subsidized or self-pay patients had significantly lower rates of resection for colorectal cancer compared with privately insured patients in both Massachusetts and the control states. The Massachusetts insurance expansion was associated with a 44% increased rate of resection (rate ratio = 1.44; 95% CI, 1.23 to 1.68; P < .001), a 6.21 percentage point decreased probability of emergent admission (95% CI, -11.88 to -0.54; P = .032), and an 8.13 percentage point increased probability of an elective admission (95% CI, 1.34 to 14.91; P = .019) compared with the control states. Conclusion The 2006 Massachusetts health care reform, a model for the Affordable Care Act, was associated with increased rates of resection and decreased probability of emergent resection for colorectal cancer. Our findings suggest that insurance expansion may help improve access to care for patients with colorectal cancer.
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Affiliation(s)
| | - Zirui Song
- All authors: Massachusetts General Hospital, Boston, MA
| | - Alex B Haynes
- All authors: Massachusetts General Hospital, Boston, MA
| | - David C Chang
- All authors: Massachusetts General Hospital, Boston, MA
| | | | - John T Mullen
- All authors: Massachusetts General Hospital, Boston, MA
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Loehrer AP, Chang DC, Hutter MM, Song Z, Lillemoe KD, Warshaw AL, Ferrone CR. Health Insurance Expansion and Treatment of Pancreatic Cancer: Does Increased Access Lead to Improved Care? J Am Coll Surg 2015; 221:1015-22. [PMID: 26611798 DOI: 10.1016/j.jamcollsurg.2015.09.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 09/09/2015] [Accepted: 09/10/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND Pancreatic cancer is increasingly common and poised to become the second leading cause of cancer deaths by the year 2020. Surgical resection is the only chance for cure, yet significant disparities in resection rates exist by insurance status. The 2006 Massachusetts health care reform serves as natural experiment to evaluate the unknown impact of health insurance expansion on treatment of pancreatic cancer. STUDY DESIGN Using the Agency for Healthcare Research and Quality's State Inpatient Databases, this cohort study examines nonelderly, adult patients with no insurance, private coverage, or government-subsidized insurance plans, who were admitted with pancreatic cancer in Massachusetts and 3 control states. The primary end point was change in pancreatic resection rates. Difference-in-difference models were used to show the impact of Massachusetts health care reform on resection rates for pancreatic cancer, controlling for confounding factors and secular trends. RESULTS Before the Massachusetts reform, government-subsidized and self-pay patients had significantly lower rates of resection than privately insured patients. The 2006 Massachusetts health reform was associated with a 15% increased rate of admission with pancreatic cancer (p = 0.043) and a 67% increased rate of surgical resection (p = 0.043) compared with control states. Measured disparities in likelihood of resection by insurance status decreased in Massachusetts and remained unchanged in control states. CONCLUSIONS The 2006 Massachusetts health care reform was associated with increased resection rates for pancreatic cancer compared with control states. Our findings provide hopeful evidence that increased insurance coverage can help improve equity in pancreatic cancer treatment. Additional studies are needed to evaluate the longevity of these findings and generalizability in other states.
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Affiliation(s)
- Andrew P Loehrer
- Department of Surgery, Massachusetts General Hospital, Boston, MA.
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Zirui Song
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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