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Lin P, Argon NT, Cheng Q, Evans CS, Linthicum B, Liu Y, Mehrotra A, Murphy L, Patel MD, Ziya S. Identifying Patient Subpopulations with Significant Race-Sex Differences in Emergency Department Disposition Decisions. Health Serv Insights 2024; 17:11786329241277724. [PMID: 39247491 PMCID: PMC11378179 DOI: 10.1177/11786329241277724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 08/08/2024] [Indexed: 09/10/2024] Open
Abstract
Background/objectives The race-sex differences in emergency department (ED) disposition decisions have been reported widely. Our objective is to identify demographic and clinical subgroups for which this difference is most pronounced, which will facilitate future targeted research on potential disparities and interventions. Methods We performed a retrospective analysis of 93 987 White and African-American adults assigned an Emergency Severity Index of 3 at 3 large EDs from January 2019 to February 2020. Using random forests, we identified the Elixhauser comorbidity score, age, and insurance status as important variables to divide data into subpopulations. Logistic regression models were then fitted to test race-sex differences within each subpopulation while controlling for other patient characteristics and ED conditions. Results In each subpopulation, African-American women were less likely to be admitted than White men with odds ratios as low as 0.304 (95% confidence interval (CI): [0.229, 0.404]). African-American men had smaller admission odds compared to White men in subpopulations of 41+ years of age or with very low/high Elixhauser scores, odds ratios being as low as 0.652 (CI: [0.590, 0.747]). White women were less likely to be admitted than White men in subpopulations of 18 to 40 or 41 to 64 years of age, with low Elixhauser scores, or with Self-Pay or Medicaid insurance status with odds ratios as low as 0.574 (CI: [0.421, 0.784]). Conclusions While differences in likelihood of admission were lessened by younger age for African-American men, and by older age, higher Elixhauser score, and Medicare or Commercial insurance for White women, they persisted in all subgroups for African-American women. In general, patients of age 64 years or younger, with low comorbidity scores, or with Medicaid or no insurance appeared most prone to potential disparities in admissions.
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Affiliation(s)
- Peter Lin
- Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, NC, USA
| | - Nilay T Argon
- Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, NC, USA
| | - Qian Cheng
- Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, NC, USA
| | - Christopher S Evans
- Information Services, ECU Health, Greenville, NC, USA
- Department of Emergency Medicine, East Carolina University, Greenville, NC, USA
| | - Benjamin Linthicum
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Yufeng Liu
- Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, NC, USA
- Department of Genetics, University of North Carolina, Chapel Hill, NC, USA
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
- Carolina Center for Genome Sciences, University of North Carolina, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Abhishek Mehrotra
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Laura Murphy
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Serhan Ziya
- Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, NC, USA
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Okewunmi J, Stern BZ, Arroyave Villada JS, Restrepo Mejia M, Zubizarreta N, Poeran J, Forsh DA. Differences in Perioperative Metrics by Race and Ethnicity and Insurance After Pelvic Fracture: A Nationwide Study. Orthopedics 2024; 47:e233-e240. [PMID: 38864645 DOI: 10.3928/01477447-20240605-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
BACKGROUND Disparities in orthopedic trauma care have been reported for racial-ethnic minority and socially disadvantaged patients. We examined differences in perioperative metrics by patient race and ethnicity and insurance after pelvic fracture in a national sample in the United States. MATERIALS AND METHODS The 2016-2019 National Inpatient Sample was queried for White, Black, and Hispanic patients 18 to 64 years old with private, Medicaid, or self-pay insurance who underwent non-elective pelvic fracture surgery. Associations between combined race and ethnicity and insurance subgroups and perioperative metrics (time to surgery, length of stay, inhospital complications, institutional discharge) were assessed using multivariable generalized linear and logistic regression models. Adjusted percent differences or odds ratios (ORs) were reported. RESULTS A weighted total of 14,375 surgeries were included (68.8% in White patients, 16.1% in Black patients, and 15.1% in Hispanic patients; 60.0% private insurance, 26.3% Medicaid, and 13.7% self-pay). Compared with White patients with private insurance, all Black insurance subgroups had longer length of stay (+15.38% to +38.78%, P≤.001), as did Hispanic patients with Medicaid (+28.03%, P<.001), White patients with Medicaid (+13.08%, P<.001), and White patients with self-pay (+9.47%, P=.04). Additionally, compared with White patients with private insurance, decreased odds of institutional discharge were observed for all patients with self-pay (OR, 0.24-0.37, P<.001) as well as White patients with Medicaid (OR, 0.70, P=.003) and Hispanic patients with Medicaid (OR, 0.57, P=.002). There were no significant adjusted associations between race and ethnicity and insurance subgroups and in-hospital complications or time to surgery. CONCLUSION These differences in perioperative metrics, primarily for Black patients and patients with self-pay insurance, warrant further examination to identify whether they reflect disparities that should be addressed to promote equitable orthopedic trauma care. [Orthopedics. 2024;47(5):e233-e240.].
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Gibson AB, Hendricks WD, Arnow K, Tran LD, Wagner TH, Knowlton LM. State-Level Variability in Hospital Presumptive Eligibility Programs. JAMA Netw Open 2023; 6:e2345244. [PMID: 38015508 PMCID: PMC10685880 DOI: 10.1001/jamanetworkopen.2023.45244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/17/2023] [Indexed: 11/29/2023] Open
Abstract
This cross-sectional study examines state-level variability in hospital presumptive eligibility programs to understand discrepancies in access by Medicaid expansion status.
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Affiliation(s)
- Alexander B. Gibson
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, California
| | - Wesley D. Hendricks
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, California
| | - Katherine Arnow
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, California
| | - Linda D. Tran
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, California
| | - Todd H. Wagner
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, California
| | - Lisa Marie Knowlton
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford, California
- Section of Trauma, Surgical Critical Care and Acute Care Surgery, Stanford University School of Medicine, Stanford, California
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4
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Gebran A, Thakur SS, Maurer LR, Bandi H, Sinyard R, Dorken-Gallastegi A, Bokenkamp M, El Moheb M, Naar L, Vapsi A, Daye D, Velmahos GC, Bertsimas D, Kaafarani HMA. Development of a Machine Learning-Based Prescriptive Tool to Address Racial Disparities in Access to Care After Penetrating Trauma. JAMA Surg 2023; 158:1088-1095. [PMID: 37610746 PMCID: PMC10448365 DOI: 10.1001/jamasurg.2023.2293] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 03/11/2023] [Indexed: 08/24/2023]
Abstract
Importance The use of artificial intelligence (AI) in clinical medicine risks perpetuating existing bias in care, such as disparities in access to postinjury rehabilitation services. Objective To leverage a novel, interpretable AI-based technology to uncover racial disparities in access to postinjury rehabilitation care and create an AI-based prescriptive tool to address these disparities. Design, Setting, and Participants This cohort study used data from the 2010-2016 American College of Surgeons Trauma Quality Improvement Program database for Black and White patients with a penetrating mechanism of injury. An interpretable AI methodology called optimal classification trees (OCTs) was applied in an 80:20 derivation/validation split to predict discharge disposition (home vs postacute care [PAC]). The interpretable nature of OCTs allowed for examination of the AI logic to identify racial disparities. A prescriptive mixed-integer optimization model using age, injury, and gender data was allowed to "fairness-flip" the recommended discharge destination for a subset of patients while minimizing the ratio of imbalance between Black and White patients. Three OCTs were developed to predict discharge disposition: the first 2 trees used unadjusted data (one without and one with the race variable), and the third tree used fairness-adjusted data. Main Outcomes and Measures Disparities and the discriminative performance (C statistic) were compared among fairness-adjusted and unadjusted OCTs. Results A total of 52 468 patients were included; the median (IQR) age was 29 (22-40) years, 46 189 patients (88.0%) were male, 31 470 (60.0%) were Black, and 20 998 (40.0%) were White. A total of 3800 Black patients (12.1%) were discharged to PAC, compared with 4504 White patients (21.5%; P < .001). Examining the AI logic uncovered significant disparities in PAC discharge destination access, with race playing the second most important role. The prescriptive fairness adjustment recommended flipping the discharge destination of 4.5% of the patients, with the performance of the adjusted model increasing from a C statistic of 0.79 to 0.87. After fairness adjustment, disparities disappeared, and a similar percentage of Black and White patients (15.8% vs 15.8%; P = .87) had a recommended discharge to PAC. Conclusions and Relevance In this study, we developed an accurate, machine learning-based, fairness-adjusted model that can identify barriers to discharge to postacute care. Instead of accidentally encoding bias, interpretable AI methodologies are powerful tools to diagnose and remedy system-related bias in care, such as disparities in access to postinjury rehabilitation care.
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Affiliation(s)
- Anthony Gebran
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Lydia R. Maurer
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston
| | - Hari Bandi
- Massachusetts Institute of Technology, Cambridge
| | - Robert Sinyard
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston
| | - Ander Dorken-Gallastegi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary Bokenkamp
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston
| | - Mohamad El Moheb
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston
| | - Leon Naar
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston
| | - Annita Vapsi
- Massachusetts Institute of Technology, Cambridge
| | - Dania Daye
- Division of Interventional Radiology, Massachusetts General Hospital, Boston
| | - George C. Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston
| | | | - Haytham M. A. Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston
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Chervu N, Branche C, Verma A, Vadlakonda A, Bakhtiyar SS, Hadaya J, Benharash P. Association of insurance status with financial toxicity and outcome disparities after penetrating trauma and assault. Surgery 2023; 173:1493-1498. [PMID: 37031053 DOI: 10.1016/j.surg.2023.02.033] [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: 12/28/2022] [Revised: 02/16/2023] [Accepted: 02/27/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Financial toxicity, or the impact out-of-pocket medical expenses have on the quality of life, has not been widely enumerated in the trauma literature. We characterized the relationship between insurance status and the risk of financial toxicity after trauma and associated risk factors. METHODS Adults admitted for gunshot wounds, other penetrating injuries, or blunt assault were identified from the 2015 to 2019 National Inpatient Sample. The outcome of interest was a risk of financial toxicity with separate regression models for uninsured and insured populations. RESULTS Of an estimated 775,665 patients, 21.2% were at risk of financial toxicity. Patients at risk of financial toxicity were younger, more commonly male, less commonly White, and had a lower Elixhauser Index (Table 1). A higher proportion of uninsured patients were at risk of financial toxicity (40.8% vs 17.7%, P < .001) than insured patients. Whereas the proportion of uninsured patients at risk of financial toxicity significantly increased from 2015 to 2019, it was unchanged in insured patients. After adjustment, non-income demographic and clinical factors were not associated with the risk of financial toxicity amongst the insured. Conversely, the Black or Hispanic race, gunshot wounds, and any in-hospital complications were some factors associated with increased risk of financial toxicity in uninsured patients. CONCLUSION An increasingly larger proportion of uninsured patients are at risk of financial toxicity after trauma. The risk of financial toxicity among the uninsured was more complex than in the insured and associated with race, gunshot wounds, and complications. Increasing insurance access and the adoption of trauma-informed care practices should be used to address financial toxicity in this population.
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Affiliation(s)
- Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, University of California-Los Angeles, CA
| | - Corynn Branche
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA. https://twitter.com/arjun_ver
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; David Geffen School of Medicine, University of California-Los Angeles, CA
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO. https://twitter.com/Aortologist
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, University of California-Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, University of California-Los Angeles, CA. https://twitter.com/CoreLabUCLA
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Mike EV, Brandsdorfer A, Parsikia A, Mbekeani JN. Disparities Associated with Discharge Patterns in Firearm-Associated Ocular Trauma. JAMA Ophthalmol 2023; 141:564-571. [PMID: 37166790 PMCID: PMC10176177 DOI: 10.1001/jamaophthalmol.2023.1467] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/15/2023] [Indexed: 05/12/2023]
Abstract
Importance Firearm injuries are associated with devastating visual outcomes. Several studies have demonstrated disparities in trauma care and discharge to rehabilitation and other advanced care facilities (ACFs) due to race and ethnicity and insurance status. The identification of possible disparities in disposition of patients admitted with firearms-associated ocular injuries (FAOIs) is a crucial step in moving toward health equity. Objective To describe disposition patterns following admission for FAOI trauma. Design, Setting, and Participants This retrospective analysis of National Trauma Data Bank (NTDB) from 2008 through 2014 used hospitalized trauma cases from over 900 US facilities detailed in the NTDB. Participants included patients admitted with ocular injuries. Statistical analysis was conducted between April 16, 2017, and December 15, 2021. Exposure Firearm injuries. Main Outcomes and Measures Patients admitted with FAOIs were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes and E-codes. Demographic data, location, injury type and severity, and insurance status were documented. The primary outcome was the odds of discharge to ACFs. Results A total of 8715 of 235 254 firearms injuries involved the eye (3.7%). Of the 8715 included patients, 7469 were male (85.7%), 3050 were African American (35.0%), and 4065 White (46.6%), with a mean (SD) age of 33.8 (16.9) years. Common payments were government insurance (31.5%), self-paid insurance (29.4%), and commercial insurance plans (22.8%). Frequent dispositions were home (48.8%) and ACF (20.5%). Multivariate analysis demonstrated that the following factors were associated with the highest odds of discharge to an ACF: hospital stays 6 days or longer (odds ratio [OR], 3.05; 95% CI, 2.56-3.63; P < .001), age 65 years or older (OR, 2.94; 95% CI, 1.94-4.48; P < .001), associated traumatic brain injury (OR, 2.32; 95% CI, 1.94-2.78; P < .001), severe traumatic brain injury (OR, 2.10; 95% CI, 1.79-2.46; P < .001), and very severe Injury Severity Score (OR, 2.22; 95% CI, 1.88-2.62; P < .001). White race (OR, 2.00; 95% CI, 1.71-2.33; P < .001) was associated with higher odds than Medicare insurance (OR, 1.64; 95% CI, 1.16-2.31; P = .01). Conclusions and Relevance These findings suggest that older, more severely injured, Medicare-insured, or White patients have higher odds of ACF placement than younger, less severely injured, otherwise insured, and Black and Hispanic patients. This study is limited by its retrospective nature and the study team was unable to explore the basis for these disposition differences. Nevertheless, this work highlights that disparities may exist in disposition after FAOIs that may limit the rehabilitation potential of specific populations.
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Affiliation(s)
- Elise V. Mike
- Johns Hopkins Wilmer Eye Institute, Baltimore, Maryland
| | - Ari Brandsdorfer
- Department of Ophthalmology & Visual Sciences, Montefiore Medical Center, Bronx, New York
- Consulting Ophthalmologists, Farmington, Connecticut
| | | | - Joyce N. Mbekeani
- Department of Surgery (Ophthalmology), Jacobi Medical Center, Bronx, New York
- Department of Ophthalmology & Visual Sciences, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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Elkbuli A, Sutherland M, Gargano T, Kinslow K, Liu H, McKenney M, Ang D. Race and Insurance Status Disparities in Post-discharge Disposition After Hospitalization for Major Trauma. Am Surg 2023; 89:379-389. [PMID: 34176320 DOI: 10.1177/00031348211029864] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Investigations detailing predictive measures of hospital disposition after traumatic injury are scarce. We aim to examine the discharge practices among trauma centers in the US and to identify factors that may influence post-hospital disposition. METHODS A retrospective analysis of trauma patients using the American College of Surgeons-Trauma Quality Improvement Program dataset from 2007-2017. Primary study outcome was hospital disposition (including long term care facility [LTC], others). Secondary outcomes included: Intensive Care Unit (ICU)-length of stay (LOS), complications, others). RESULTS 6 899 538 patients were analyzed. Odds of LTC discharge was significantly higher for Black patients (aOR = 1.30, 95% CI:1.24-1.37), abbreviated injury score (AIS) ≥3 (aOR = 4.22, 95% CI: 4.05-4.39), and higher injury severity score (ISS) (aOR = 9.41, 95% CI:9.03-9.80). Significantly more self-pay patients were discharged home compared to other insurance types (P < .0001). Significantly longer hospital- and ICU-LOS were experienced by those who had an AIS ≥3 (hospital: 4.8 days (±7.1) vs. 7.9 (±10.1); ICU: 4.6 (±6.9) vs. 5.9 (±7.9), P < .0001) and had a high ISS (hospital: 4.5 days (±5.9) vs. 16.8 (±17.9); ICU: 3.6 (±5.0) vs. 10.2 (±11.5), P < .0001). CONCLUSIONS Patient race, insurance status, and injury severity were predictive of post-hospitalization care discharge. Self-pay and Black patients were less likely to be discharged to secondary care facilities. These findings have the potential to improve in-hospital patient management and predict discharge secondary care needs, and necessitate the need for future research to investigate the extent of inequalities in access to trauma care.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Toria Gargano
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Kyle Kinslow
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Huazhi Liu
- Department of Surgery, 23703Ocala Regional Medical Center, Ocala, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA.,Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Darwin Ang
- Department of Surgery, 23703Ocala Regional Medical Center, Ocala, FL, USA.,Department of Surgery, University of Central Florida, Ocala, FL, USA
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Knowlton LM, Tran LD, Arnow K, Trickey AW, Morris AM, Spain DA, Wagner TH. Emergency Medicaid programs may be an effective means of providing sustained insurance among trauma patients: A statewide longitudinal analysis. J Trauma Acute Care Surg 2023; 94:53-60. [PMID: 36138539 PMCID: PMC9805493 DOI: 10.1097/ta.0000000000003796] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization that offsets costs of care, increases access to postdischarge resources, and provides patients with a path to sustain coverage through Medicaid. Because HPE only lasts up to 60 days, we aimed to determine Medicaid insurance status 6 months after injury among HPE-approved trauma patients and identify factors associated with successful sustainment. METHODS Using a customized longitudinal claims data set for HPE-approved patients from the California Department of Health Care Services, we analyzed adults with a primary trauma diagnosis (International Classification of Diseases version 10) who were HPE approved in 2016 and 2017. Our primary outcome was Medicaid sustainment at 6 months. Univariate and multivariate analyses were performed. RESULTS A total of 9,749 trauma patients with HPE were analyzed; 6,795 (69.7%) sustained Medicaid at 6 months. Compared with patients who did not sustain, those who sustained had higher Injury Severity Score (ISS > 15: 73.5% vs. 68.7%, p < 0.001), more frequent surgical intervention (74.8% vs. 64.5%, p < 0.001), and were more likely to be discharged to postacute services (23.9% vs. 10.4%, p < 0.001). Medicaid sustainment was high among patients who identified as White (86.7%), Hispanic (86.7%), Black (84.3%), and Asian (83.7%). Medicaid sustainment was low among the 2,505 patients (25.7%) who declined to report race, ethnicity, or preferred language (14.8% sustainment). In adjusted analyses, major injuries (ISS > 16) (vs. ISS < 15: adjusted odds ratio [aOR], 1.51; p = 0.02) and surgery (aOR, 1.85; p < 0.001) were associated with increased likelihood of Medicaid sustainment. Declining to disclose race, ethnicity, or language (aOR, 0.05; p < 0.001) decreased the likelihood of Medicaid sustainment. CONCLUSION Hospital Presumptive Eligibility programs are a promising pathway for securing long-term insurance coverage for trauma patients, particularly among the severely injured who likely require ongoing access to health care services. Patient and provider interviews would help to elucidate barriers for patients who do not sustain. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Lisa Marie Knowlton
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - Linda D. Tran
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - Katherine Arnow
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - Arden M. Morris
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - David A. Spain
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Todd H. Wagner
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
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Kleber KT, Kravitz-Wirtz N, Buggs SL, Adams CM, Sardo AC, Hoch JS, Brown IE. Emergency department visit patterns in the recently discharged, violently injured patient: Retrospective cohort review. Am J Surg 2023; 225:162-167. [PMID: 35871849 DOI: 10.1016/j.amjsurg.2022.07.005] [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: 01/20/2022] [Revised: 06/21/2022] [Accepted: 07/14/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Analysis of the costs associated with emergency department (ED) visits after discharge for violent injury could highlight subgroups for the development of cost-effective interventions to support healing and prevent treatment failures in violently injured patients. METHODS A retrospective cohort review was conducted of all patients with return ED visits within 90 days of discharge after treatment for a violent injury occurring between July 1, 2016, and June 30, 2018. Hospital costs were calculated for each incidence and analyzed against demographic and injury type variables to identify trends. RESULTS 218 return ED visits were identified. Hospital costs showed a high frequency of low-cost visits. For more complex visits, distinct cost patterns were observed for Black and LatinX males compared to White males as a function of age. CONCLUSIONS Analysis of hospital cost per visit identified trends among different subgroups. Underlying etiologies presumably vary between groups, but hypothesis-driven further investigation and needs assessment is required. Understanding the driving forces behind these cost trends may aid in developing effective interventions.
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Affiliation(s)
- Kara T Kleber
- Department of Surgery, University of California Davis School of Medicine, 235 Stockton Blvd, Sacramento, CA, 95817, USA.
| | - Nicole Kravitz-Wirtz
- Violence Prevention Research Program, Department of Emergency Medicine, University of California Davis School of Medicine, 2315 Stockton Blvd, Sacramento, CA, 95817, USA.
| | - Shani L Buggs
- Violence Prevention Research Program, Department of Emergency Medicine, University of California Davis School of Medicine, 2315 Stockton Blvd, Sacramento, CA, 95817, USA.
| | - Christy M Adams
- Trauma Prevention Program, UC Davis Health, University of California Davis, 4900 Broadway, Suite 1650, Sacramento, CA, 95820, USA.
| | - Angela C Sardo
- University of California Davis School of Medicine, 4610 X St, Sacramento, CA, 95817, USA.
| | - Jeffrey S Hoch
- Division of Health Policy and Management, Department of Public Health Sciences and Center for Healthcare Policy and Research, University of California Davis, 4900 Broadway, Suite 1430, Sacramento, CA, 95820, USA.
| | - Ian E Brown
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery University of California Davis Medical Center, 2335 Stockton Blvd, Sacramento, CA, 95817, USA.
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Simpson JT, Hussein MH, Toraih EA, Suess M, Tatum D, Taghavi S, McGrew P. Trends and Burden of Firearm-Related Injuries Among Children and Adolescents: A National Perspective. J Surg Res 2022; 280:63-73. [PMID: 35963016 DOI: 10.1016/j.jss.2022.06.065] [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: 11/23/2021] [Revised: 06/25/2022] [Accepted: 06/30/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Firearm-related injuries in America have been under increasing scrutiny over the last several years. Few studies have examined the burden of these injuries in the pediatric population. The objective of this study was to describe the incidence of firearm-related injuries in hospitalized pediatric patients in the United States and identify the risk factors associated with readmission in this young population. METHODS The Nationwide Readmission Database was examined from 2010 to 2017. Pediatric patients (aged ≤18 y) who survived their index hospitalization for any firearm injury were analyzed to determine incidence rate, case fatality rate, risk factors for 30-d readmission, and financial health care burden. RESULTS There were 35,753 pediatric firearm injuries (86.8% male) with an overall incidence rate of 10.49 (95% confidence interval [CI]: 9.26-11.71) per 100,000 pediatric hospitalizations. Adolescents aged >12 y had the highest incidence rate (60.51, 95% CI: 55.19-65.84). In-hospital mortality occurred in 1948 cases (5.5%), with higher case fatality rates in males. There were 1616 (5.7%) unplanned 30-d readmissions. Multivariate analysis showed abdominal firearm injuries (hazard ratio: 1.13, 95% CI: 1.03-1.24; P = 0.006) and longer length of stay (hazard ratio: 1.27, 95% CI: 1.04-1.55; P = 0.016) were associated with a greater risk of 30-d readmission. The median health care cost for firearm-related injuries was $36,535 (interquartile range: $19,802-$66,443), 22% of which was due to readmissions. Cost associated with 30-d readmissions was $7978 (interquartile range: $4305-$15,202). CONCLUSIONS Firearm-related injury is a major contributor to pediatric morbidity, mortality, and health care costs. Males are disproportionately affected by firearm injury, but females are more likely to require unplanned 30-d readmissions. Interventions should target female sex, injuries of suicidal intent, psychiatric comorbidities, prolonged index hospitalization, and abdominal injuries.
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Affiliation(s)
- John T Simpson
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana.
| | | | - Eman Ali Toraih
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana; Genetics Unit, Faculty of Medicine, Department of Histology and Cell Biology, Suez Canal University, Ismailia, Egypt
| | | | - Danielle Tatum
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Sharven Taghavi
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Patrick McGrew
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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Hagan MJ, Pertsch NJ, Leary OP, Ganga A, Sastry R, Xi K, Zheng B, Behar M, Camara-Quintana JQ, Niu T, Sullivan PZ, Abinader JF, Telfeian AE, Gokaslan ZL, Oyelese AA, Fridley JS. Influence of socioeconomic factors on discharge disposition following traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States. NORTH AMERICAN SPINE SOCIETY JOURNAL 2022; 12:100186. [PMID: 36479003 PMCID: PMC9720595 DOI: 10.1016/j.xnsj.2022.100186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/04/2022] [Accepted: 11/19/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Discharge to acute rehabilitation is strongly correlated with functional recovery after traumatic injury, including spinal cord injury (SCI). However, services such as acute care rehabilitation and Skilled Nursing Facilities (SNF) are expensive. Our objective was to understand if high-cost, resource-intensive post-discharge rehabilitation or alternative care facilities are utilized at disparate rates across socioeconomic groups after SCI. METHODS We performed a cohort analysis using the National Trauma Data Bank® tabulated from 2012-2016. Eligible patients had a diagnosis of cervical or thoracic spine fracture with spinal cord injury (SCI) and were treated surgically. We evaluated associations of sociodemographic and psychosocial variables with non-home discharge (e.g., discharge to SNF, other healthcare facility, or intermediate care facility) via multivariable logistic regression while correcting for injury severity and hospital characteristics. RESULTS We identified 3933 eligible patients. Patients who were older, male (OR=1.29 95% Confidence Interval [1.07-1.56], p=.007), insured by Medicare (OR=1.45 [1.08-1.96], p=.015), diagnosed with a major psychiatric disorder (OR=1.40 [1.03-1.90], p=.034), had a higher Injury Severity Score (OR=5.21 [2.96-9.18], p<.001) or a lower Glasgow Coma Score (3-8 points, OR=2.78 [1.81-4.27], p<.001) had a higher chance of a non-home discharge. The only sociodemographic variable associated with lower likelihood of utilizing additional healthcare facilities following discharge was uninsured status (OR=0.47 [0.37-0.60], p<.001). CONCLUSIONS Uninsured patients are less likely to be discharged to acute rehabilitation or alternative healthcare facilities following surgical management of SCI. High out-of-pocket costs for uninsured patients in the United States may deter utilization of these services.
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Affiliation(s)
- Matthew J. Hagan
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
| | - Nathan J. Pertsch
- Department of Neurosurgery, Rush University Medical Center, 600 S. Paulina St, Chicago, IL 60612, USA
| | - Owen P. Leary
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Arjun Ganga
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Rahul Sastry
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Kevin Xi
- Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA
| | - Bryan Zheng
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
| | - Mark Behar
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
| | - Joaquin Q. Camara-Quintana
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Tianyi Niu
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Patricia Zadnik Sullivan
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Jose Fernandez Abinader
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Albert E. Telfeian
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Ziya L. Gokaslan
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Adetokunbo A. Oyelese
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Jared S. Fridley
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
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12
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He C, Parsikia A, Mbekeani JN. Disparities in discharge patterns of admitted older patients with ocular trauma. Injury 2022; 53:2016-2022. [PMID: 35197206 DOI: 10.1016/j.injury.2022.02.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 02/07/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE In older patients, poor vision from ocular trauma increases the likelihood of further injuries and repeat hospitalizations, underscoring the need for appropriate post-hospitalization care. We sought to evaluate disposition patterns of older patients admitted with ocular trauma. METHODS/MATERIALS This retrospective observational study analyzed the National Trauma Data Bank (2008-2014) and de-identified data of patients, ≥65 years old, admitted with ocular trauma were identified using ICD-9CM and E-codes. Age, gender, race/ethnicity, type of ocular injury, comorbidities, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, length of hospital stay, location and US region, insurance, and discharge disposition were extracted. Analysis was performed with student's t-test, Chi-squared test, and odds ratios (OR) using SPSS software. Statistical significance was set at P <.05. RESULTS 58,074 (18.3%) of 316,485 patients admitted with ocular trauma were >65yrs. 26,346 (45.4%) were discharged home and 23,314 (40.1%) to an advanced care facility (ACF). Nursing home residents were most likely to return to ACF (OR, 4.76; 95%CI, 4.40-5.14; P < .001). Patients with severe traumatic brain injury (Glasgow coma score [GCS]<8) (OR, 4.57; 95%CI, 4.09-5.11; P < .001), very severe injury severity score (ISS ≥24) (OR, 3.73; 95%CI, 3.46-4.01; P < .001), females (OR, 1.27; 95%CI, 1.23-1.32; P < .001), white patients (OR, 1.29; 95%CI, 1.24-1.36; P < .001) and Medicare beneficiaries (OR, 1.14; 95%CI, 1.09-1.19; P < .001) were most likely to be discharged to an ACF. Demography-related discharge propensities prevailed nationwide and within insurance categories. Multivariate regression analysis revealed factors determining ACF placement were, in order: length of hospital stay, nursing home residency, GCS<8, ISS>24, female gender, white race, and Medicare insurance. CONCLUSIONS Hispanic, black, male, and self-paying patients were disproportionately discharged home. Ocular injuries had low impact on ACF placement. Understanding these disparities will assist in developing guidelines for appropriate and equitable post-trauma rehabilitation in this vulnerable population.
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Affiliation(s)
- Catherine He
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA.
| | - Afshin Parsikia
- Department of Surgery (Trauma), Jacobi Medical Center, 1400 Pelham Parkway, Bronx, NY 10461, USA.
| | - Joyce N Mbekeani
- Department of Surgery (Ophthalmology), Jacobi Medical Center, 1400 Pelham Parkway, Bronx, NY 10461, USA; Department of Ophthalmology & Visual Sciences, Albert Einstein College of Medicine, Bronx, 1300 Morris Park Avenue, NY 10461, USA.
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13
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Lu J, Gormley M, Donaldson A, Agyemang A, Karmarkar A, Seel RT. Identifying factors associated with acute hospital discharge dispositions in patients with moderate-to-severe traumatic brain injury. Brain Inj 2022; 36:383-392. [PMID: 35213272 DOI: 10.1080/02699052.2022.2034180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Identify sociodemographic, injury, and hospital-level factors associated with acute hospital discharge dispositions following acute hospitalization for moderate-to-severe traumatic brain injury (TBI) in the United States. METHODS The 2011-2014 National Trauma Data Bank data was used, including 466 acute care hospitals and 114,736 patients ≥16 years old who survived moderate-to-severe TBI. Outcome was acute hospital discharge dispositions: home with/without care (HC), skilled nursing home/other care facility (SNF/ICF) and inpatient rehabilitation/long-term care facility (IRF). Independent variables were patients' sociodemographic, injury, and hospital-level factors. Multilevel modeling was used to assess associations and compare likelihood of discharges. RESULTS Of all patients, 74.5%, 14.6% ,and 10.9% were discharged to HC, SNF/ICF ,and IRF, respectively. Intraclass correlation coefficients indicated that hospitals explained 14.3% and 14.8% of variations in probabilities of institution dispositions. Sociodemographic factors including older age, females, Non-Hispanic Whites, recipients of commercial insurance, and Medicare/Medicaid were significantly associated with higher institution discharges. Hospital-related factors including bed size, teaching status, trauma accreditations, and hospital locations were significantly associated with discharge dispositions. CONCLUSION Identifying factors associated with discharge dispositions after acute hospitalization of TBI is pertinent to ensure quality of care and optimal patient outcomes. Further research into hospital-related variations in acute care discharge dispositions is recommended.
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Affiliation(s)
- Juan Lu
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Mirinda Gormley
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Alexis Donaldson
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Amma Agyemang
- Center for Rehabilitation Science and Engineering (CERSE), Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Amol Karmarkar
- Center for Rehabilitation Science and Engineering (CERSE), Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ronald T Seel
- Center for Rehabilitation Science and Engineering (CERSE), Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
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Prescher H, Haravu P, Silva AK, Reid RR, Wang F. Trauma clinic follow-up: Predictors of nonattendance and patient-reported reasons for no show. TRAUMA-ENGLAND 2022. [DOI: 10.1177/14604086211052795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction The objectives of this study were to identify factors associated with nonattendance to follow-up in patients seen for traumatic hand and facial injuries at an urban Level 1 trauma center and to elucidate patient-reported reasons for nonattendance. Methods A retrospective chart review was performed for all patients seen for hand and facial trauma at our institution over a 2-year period. Demographic data, including race, insurance status, and incomes based on zip code data, were collected for all patients. Injury patterns, interventions, and patient disposition were analyzed. A binomial multivariate logistic regression was conducted to identify predictors of nonattendance to follow-up. All patients who were lost to follow-up over the last 12-month period were contacted via phone to identify reasons for nonattendance to determine whether they had followed up with another provider and to analyze long-term injury sequelae. Results After exclusion criteria were applied, there were 889 patients included in the analysis, with 31% of patients lost to follow-up. Factors significantly associated with follow-up nonattendance included patients who sustained injuries from gunshot wounds or assault, had no insurance or were out of network, and who received no acute intervention for their injuries. Forearm, wrist, and fingers fractures; facial fractures and lacerations; performing a procedure in the ED or operating room; and commercial insurance were all independent predictors of clinic attendance. The most common reasons for nonattendance cited by patients were “did not feel the need” (28%), lack of transportation (20%), and scheduling conflicts (19%). Conclusions Clinic follow-up for patients sustaining hand and facial trauma at a Level 1 trauma center is impacted by the socioeconomic factors that make this patient population particularly vulnerable to injury.
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Affiliation(s)
- Hannes Prescher
- Section of Plastic and Reconstructive Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Pranav Haravu
- Section of Plastic and Reconstructive Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Amanda K Silva
- Section of Plastic and Reconstructive Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Russell R Reid
- Section of Plastic and Reconstructive Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Frederick Wang
- Section of Plastic and Reconstructive Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
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Lussiez A, Montgomery JR, Sangji NF, Fan Z, Oliphant BW, Hemmila MR, Dimick JB, Scott JW. Hospital effects drive variation in access to inpatient rehabilitation after trauma. J Trauma Acute Care Surg 2021; 91:413-421. [PMID: 34108424 PMCID: PMC8375412 DOI: 10.1097/ta.0000000000003215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postacute care rehabilitation is critically important to recover after trauma, but many patients do not have access. A better understanding of the drivers behind inpatient rehabilitation facility (IRF) use has the potential for major cost-savings as well as higher-quality and more equitable patient care. We sought to quantify the variation in hospital rates of trauma patient discharge to inpatient rehabilitation and understand which factors (patient vs. injury vs. hospital level) contribute the most. METHODS We performed a retrospective cohort study of 668,305 adult trauma patients admitted to 900 levels I to IV trauma centers between 2011 and 2015 using the National Trauma Data Bank. Participants were included if they met the following criteria: age >18 years, Injury Severity Score of ≥9, identifiable injury type, and who had one of the Centers for Medicare & Medicaid Services preferred diagnoses for inpatient rehabilitation under the "60% rule." RESULTS The overall risk- and reliability-adjusted hospital rates of discharge to IRF averaged 18.8% in the nonelderly adult cohort (18-64 years old) and 23.4% in the older adult cohort (65 years or older). Despite controlling for all patient-, injury-, and hospital-level factors, hospital discharge of patients to IRF varied substantially between hospital quintiles and ranged from 9% to 30% in the nonelderly adult cohort and from 7% to 46% in the older adult cohort. Proportions of total variance ranged from 2.4% (patient insurance) to 12.1% (injury-level factors) in the nonelderly adult cohort and from 0.3% (patient-level factors) to 26.0% (unmeasured hospital-level factors) in the older adult cohort. CONCLUSION Among a cohort of injured patients with diagnoses that are associated with significant rehabilitation needs, the hospital at which a patient receives their care may drive a patient's likelihood of recovering at an IRF just as much, if not more, than their clinical attributes. LEVEL OF EVIDENCE Care management, level IV.
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Affiliation(s)
- Alisha Lussiez
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
| | - John R Montgomery
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
| | - Naveen F Sangji
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Bryant W Oliphant
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Mark R Hemmila
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
| | - John W Scott
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
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16
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Chou A, Euloth T, Matcho B, Pastva AM, Bilderback A, Freburger JK. Is Discordance Between Recommended and Actual Postacute Discharge Setting a Risk Factor for Readmission in Patients With Congestive Heart Failure? J Am Heart Assoc 2021; 10:e020425. [PMID: 34320844 PMCID: PMC8475711 DOI: 10.1161/jaha.120.020425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Readmissions in patients with congestive heart failure are common and often preventable. Limited data suggest that patients discharged to a less intensive postacute care setting than recommended are likely to readmit. We examined whether postacute setting discordance (discharge to a less intensive postacute setting than recommended by a physical and occupational therapist) was associated with hospital readmission in patients with congestive heart failure. We also assessed sociodemographic and clinical predictors of setting discordance. Methods and Results Retrospective analysis of administrative claims and electronic health record data was conducted on 25 500 adults with a discharge diagnosis of congestive heart failure from 12 acute care hospitals in Western Pennsylvania. Generalized linear mixed models were estimated to examine the association between postacute setting discordance and 30‐day hospital readmission and to identify predictors of setting discordance. The 30‐day readmission and postacute setting discordance rates were high (23.7%, 20.6%). While controlling for demographic and clinical covariates, patients in discordant postacute settings were more likely to be readmitted within 30 days (adjusted odds ratio [OR], 1.12; 95% CI, 1.04–1.20). The effect was also seen in the subgroup of patients with low mobility scores (adjusted OR, 1.20; 95% CI, 1.08–1.33). Factors associated with setting discordance were lower‐income, higher comorbidity burden, therapist recommendation disagreement, and midrange mobility limitations. Conclusions Postacute setting discordance was associated with an increased readmission risk in patients hospitalized with congestive heart failure. Maximizing concordance between therapist recommended and actual postacute discharge setting may decrease readmissions. Understanding factors associated with post‐acute setting discordance can inform strategies to improve the quality of the discharge process.
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Affiliation(s)
- Aileen Chou
- Department of Physical Therapy University of Pittsburgh PA
| | | | | | - Amy M Pastva
- Department of Orthopaedic Surgery Division of Physical Therapy, and Duke Claude D. Pepper Older Americans Independence Center Duke University School of Medicine Durham NC
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Alaniz L, Billimek J, Figueroa C, Nahmias JT, Barrios C. Increased Mortality in Underinsured Penetrating Trauma Patients. Am Surg 2021; 87:1594-1599. [PMID: 34128407 DOI: 10.1177/00031348211024974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION It remains unclear whether an increased mortality risk in uninsured patients exists across Injury Severity Score (ISS) classifications. We hypothesized that penetrating trauma self-pay patients would have a similarly increased mortality risk across all ISS categories. METHODS The National Trauma Data Bank (2013-2015) was queried for patients presenting with penetrating firearm, explosive, or stab wound injuries. 115 651 patients were identified and a stratified multivariable logistic regression model was used. RESULTS In the >15 ISS group, self-pay patients had a lower median total hospital Length of Stay (LOS) (3 vs 8, P < .001), lower median Intensive Care Unit LOS (1 vs 3, P < .001), and lower median ventilator days (0 vs 1, P < .001). Self-pay patients had an increased risk for mortality compared to patients with private insurance in both the ≤15 ISS group (OR 2.68, P < .001) and >15 ISS group (OR 1.56, P < .001). CONCLUSION Uninsured patients have an increased mortality risk in both low and high ISS groups. A higher mortality risk among uninsured patients in the high ISS group can be explained by decreased resource availability and lower ICU days and ventilator time. However, more studies are needed to determine why there is an even greater mortality risk among uninsured patients with mild ISS.
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Affiliation(s)
- Leonardo Alaniz
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA.,School of Medicine, University of California, Irvine, CA, USA
| | - John Billimek
- School of Medicine, University of California, Irvine, CA, USA
| | - Cesar Figueroa
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Jeffry T Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Cristobal Barrios
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
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Olafson SN, Cohen RB, Parsikia A, Moran B, Kaplan MJ, Leung P. Insurance Status Impacts Hospital Discharge for Penetrating Trauma Survivors. Am Surg 2021; 88:1996-2002. [PMID: 34053228 DOI: 10.1177/00031348211023396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite equalized acute care in trauma, disparities exist in the long-term outcomes of trauma survivors. Prior studies have revealed insurance status plays a role in the discharge destination of blunt trauma survivors. This is yet to be described in patients with penetrating traumatic injury. METHODS A retrospective chart review from 2009 to 2019 from an urban Level 1 trauma center identified adult patients who survived penetrating trauma to discharge. Patients were categorized by insurance status. Patient demographics, discharge destination, and hospital length of stay (LOS) were analyzed using the t-test and ANOVA. RESULTS 1806 patients were identified with 1410 survivors to hospital discharge. Among the survivors, 26.8% were uninsured, 13.1% were privately insured, and 60.0% had Medicare/Medicaid. The uninsured patients were significantly less likely to be discharged to a rehabilitation facility or skilled nursing facility (OR = .49, 95% CI .35-.71) compared to the insured patients. Uninsured survivors had shorter LOS compared to the other groups (5.8 vs. 7.3, P < .01.) Severity of injury did not significantly influence the discharge destination or LOS between the groups. CONCLUSION Despite recent health care reform, many trauma patients remain uninsured. Our study shows that uninsured penetrating trauma survivors are less likely to be discharged to rehabilitation and skilled nursing facilities. This may contribute to uninsured trauma survivors not receiving appropriate post-traumatic care and could lead to the accrual of undue disability, long-term complications, and increased societal burdens.
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Affiliation(s)
- Samantha N Olafson
- Department of Surgery, 6566Einstein Medical Center, Philadelphia, PA, USA
| | - Ryan B Cohen
- Department of Surgery, 6566Einstein Medical Center, Philadelphia, PA, USA
| | - Afshin Parsikia
- Department of Surgery, 6566Einstein Medical Center, Philadelphia, PA, USA
| | - Benjamin Moran
- Department of Surgery, 6566Einstein Medical Center, Philadelphia, PA, USA
| | - Mark J Kaplan
- Department of Surgery, 6566Einstein Medical Center, Philadelphia, PA, USA
| | - Pak Leung
- Department of Surgery, 6566Einstein Medical Center, Philadelphia, PA, USA
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Boutrous ML, Tian Y, Brown D, Freeman CA, Smeds MR. Area Deprivation Index Score is Associated with Lower Rates of Long Term Follow-up after Upper Extremity Vascular Injuries. Ann Vasc Surg 2021; 75:102-108. [PMID: 33910047 DOI: 10.1016/j.avsg.2021.03.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/17/2021] [Accepted: 03/19/2021] [Indexed: 11/15/2022]
Abstract
The Area Deprivation Index (ADI) has been shown to be a determinant of healthcare outcomes in both medical and surgical fields, and is a measure of the socioeconomic status of patients. We sought to analyze outcomes in patients with upper extremity vascular injuries that were admitted over a five-year period to a Level I trauma center sorted by ADI. All patients with upper extremity vascular injury presenting to a level one trauma center between January 2013 and January 2017 were retrospectively collected. The patients were divided into two groups based on their ADI with the first group representing the lowest quartile of patients and the second group the higher three quartiles. Patient's demographics were analyzed as well as modes of trauma, hospital transfer status prior to receiving care, type of intervention received, follow-up rates and outcomes including both complication and amputation rates. Over this time period, a total of 88 patients with traumatic upper extremity vascular injuries were identified. The majority of injuries were due to penetrating trauma (74/88, 84%) with 41% (10/24) of patients in the lower ADI being victims of gunshot wounds compared to 27% (17/64) of those in the higher ADI (P = 0.19). Patients in the lowest ADI quartile were more likely to be African Americans (P= 0.0001), and more likely to be transferred to our university hospital prior to receiving care (P= 0.007). Arrival Glasgow Coma Scale and Injury Severity Score were similar as was time spent in the emergency room. Length of stay trended longer in the lowest ADI quartile as compared to the higher ADI (7.5 vs. 11.8, P= 0.59). The rates of long term follow-up were significantly lower in patients with the lowest ADI scores as opposed to the higher ADI group (P= 0.0098), however, there was no statistically significant difference in outcomes between the two groups including both complication and amputation rates. The ADI is associated with lower rates of long term follow-up after upper extremity vascular injuries, despite patients in both the high and low ADI groups having similar outcomes in regards to complication and amputation rates. Further study is warranted to investigate the role of the socioeconomic status in outcomes following traumatic injury.
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Affiliation(s)
- Mina L Boutrous
- Division of Vascular and Endovascular Surgery, University of Connecticut, Farmington, CT, USA.
| | - Yuqian Tian
- Division of Vascular and Endovascular Surgery, St. Louis University, St. Louis, MO, USA
| | - Daniel Brown
- Division of Vascular and Endovascular Surgery, St. Louis University, St. Louis, MO, USA
| | - Carl A Freeman
- Trauma and Surgical Critical Care Division, St. Louis University, St. Louis, MO, USA
| | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, St. Louis University, St. Louis, MO, USA
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Winter M, Vernon T, Morgan M, Bresz K, Cook A, Bradburn E, Rogers F. The effect of the Affordable Care Act on rates on inpatient rehabilitation hospital admission in a mature trauma system. J Trauma Acute Care Surg 2021; 90:544-549. [PMID: 33492108 DOI: 10.1097/ta.0000000000003046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The beneficial effects of acute rehabilitation for trauma patients are well documented but can be limited because of insurance coverage. The Patient Protection and Affordable Care Act (ACA) went into effect on March 23, 2010. The ACA allowed patients who previously did not have insurance to be fully incorporated into the health system. We sought to analyze the likelihood of discharge to rehab for trauma patients before and after the implementation of the ACA. We hypothesized that there would be a higher rate of inpatient rehabilitation hospital (IRH) admission after the ACA was put into effect. METHODS The Pennsylvania Trauma Outcome Study (PTOS) database was retrospectively queried from 2003 to 2017 for all trauma patients admitted to accredited trauma centers in Pennsylvania, who also had a functional status at discharge (FSD). Admission to an IRH was determined using discharge destination. Two categories were created to represent periods before and after ACA was implemented, 2003 to 2009 (pre-ACA) and 2010-2017 (post-ACA). A multilevel mixed-effects logistic regression model controlling for demographics, injury severity, and FSD assessed the adjusted impact of ACA implementation on IRH admissions. RESULTS From the Pennsylvania Trauma Outcome Study query, 341,252 patients had FSD scores and of these patients, 47,522 (13.9%) were admitted to IRH. Patients who were severely injured were more likely to be admitted to IRH. Compared with FSD scores signifying complete independence at discharge, those with lower FSD had significantly increased odds of IRH admission. The odds of IRH admission post-ACA implementation significantly increased when compared with pre-ACA years (adjusted odds ratio, 1.14; 95% confidence interval, 1.12-1.17; p < 0.001; area under the receiver operating curve, 0.818). CONCLUSION The implementation of the ACA significantly increased the likelihood of discharge to IRH for trauma patients. LEVEL OF EVIDENCE Care management, level III.
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Affiliation(s)
- Mike Winter
- From the Department of Surgery (M.W.), Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania; Department of Trauma and Acute Care Surgery (T.V., M.M, K.B., E.B., F.R.), Penn Medicine Lancaster General Health, Lancaster, Pennsylvania; and Department of Surgery, University of Texas Health Science Center at Tyler (A.C.), UT Health East Texas, Tyler, Texas
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Morgan ME, Horst MA, Vernon TM, Fallat ME, Rogers AT, Bradburn EH, Rogers FB. An analysis of pediatric social vulnerability in the Pennsylvania trauma system. J Pediatr Surg 2020; 55:2746-2751. [PMID: 32595036 DOI: 10.1016/j.jpedsurg.2020.05.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The social vulnerability index (SVI) is used to assess resilience to external influences that may affect human health. Social vulnerability has been noted to be a barrier to healthcare access for pediatric patients. We hypothesized that Pennsylvania (PA) pediatric trauma patients high on the social vulnerability index would have significantly lower rates of rehab admission following admission to a hospital for traumatic injury. METHODS The SVI was determined for each PA zip code area utilizing the census tract based 2014 SVI provided by the CDC along with a weighted crosswalk between census tracts and zip code areas using the Housing and Urban Development zip code crosswalk files. The rate of the uninsured population was extracted from the CDC SVI files in addition to other US Census variables based upon estimates from the 2014 American Community Survey (ACS). We also included the individual primary payer status of each subject. Pediatric (age <15 years) trauma admissions with in-hospital mortality excluded, were extracted from the PA Healthcare Cost Containment Council (PHC4) for all hospital admissions for the period of 2003-2015 (n = 63,545). Complete case analysis was conducted based upon the final model providing a sample of 52,794. Cases were coded as rehab patients based upon discharge status (n = 603; 1.1%). A multi-level logistic model was used to determine if subjects had a higher odds of being discharged to rehab based on SVI, undertriage rates of their zip code area of residence and their own primary payer status; this was adjusted for age, multi-system injury and a head, chest or abdomen injury with abbreviate injury scale (AIS) severity > = 3. RESULTS SVI and undertriage rates of the zip code areas of residence were not significantly associated with admission to rehab. The individual primary payer status of the subject was significantly associated with admission to rehab (OR 95%CI vs. self/uninsured; Medicaid 3.65 1.84-7.24; Commercial = 3.09 1.56-6.11; other/unknown = 2.85 1.02-7.93). Admission to rehab was also significantly associated with age, injury severity (ISS), head or chest injury with AIS scores > = 3, year of admission and hospital type. CONCLUSION Individual patient level factors (primary payer of patient) may be associated with the odds of rehab admission rather than neighborhood factors. LEVEL OF EVIDENCE Epidemiologic: Level III.
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Affiliation(s)
- Madison E Morgan
- Trauma & Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Michael A Horst
- Research Institute, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Tawnya M Vernon
- Research Institute, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Mary E Fallat
- The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Amelia T Rogers
- The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Eric H Bradburn
- Trauma & Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Frederick B Rogers
- Trauma & Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA.
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Abstract
INTRODUCTION Attending clinic appointments after injury is crucial for orthopaedic trauma patients to evaluate healing and to update recommendations. However, attendance at these appointments is inconsistent. The purpose of this study was to assess the effect of a personalized phone call placed 3 to 5 days after hospital discharge on attendance at the first postdischarge outpatient clinic visit. METHODS This prospective study was done at an urban level 1 trauma center. One hundred fifty-nine patients were exposed to a reminder phone call, with 33% of patients being reached for a conversation and 28% receiving a voicemail reminder. Phone calls were made by a trained trauma recovery coach, and the main outcome measure was attendance at the first postdischarge clinic visit. RESULTS Eighty-six patients (54%) attended their scheduled appointments. Appointment adherence was more common among the group reached for a conversation (70% versus 51% for voicemail cohort and 34% for no contact group). Patients exposed to the Trauma Recovery Services (TRS) during their hospital stay attended appointments more often (91% versus 61%, P = 0.026). Age, sex, mechanism of injury, and distance from the hospital were not associated with specific follow-up appointment adherence. Insured status was associated with higher attendance rates (71% versus 46%, P = 0.0036). Other economic factors such as employment were also indicative of attendance (64% versus 48%, P = 0.05). Current tobacco use was associated with poor appointment attendance (30%) versus 56% for nonsmokers (P = 0.001). DISCUSSION Patients reached by telephone after discharge had better rates of subsequent clinic attendance. Economic factors and substance use appear vital to postoperative clinic visit compliance. Patients with met psychosocial needs, as identified by individuals with satisfactory emotional support, and exposure to TRS had the highest rates of postdischarge appointment attendance.
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Graham M, Parikh P, Hirpara S, McCarthy MC, Haut ER, Parikh PP. Predicting Discharge Disposition in Trauma Patients: Development, Validation, and Generalization of a Model Using the National Trauma Data Bank. Am Surg 2020; 86:1703-1709. [DOI: 10.1177/0003134820949523] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Limited work has been done in predicting discharge disposition in trauma patients; most studies use single institutional data and have limited generalizability. This study develops and validates a model to predict, at admission, trauma patients’ discharge disposition using NTDB, transforms the model into an easy-to-use score, and subsequently evaluates its generalizability on institutional data. Methods NTDB data were used to build and validate a binary logistic regression model using derivation-validation (ie, train-test) approach to predict patient disposition location (home vs non-home) upon admission. The model was then converted into a trauma disposition score (TDS) using an optimization-based approach. The generalizability of TDS was evaluated on institutional data from a single Level I trauma center in the U.S. Results A total of 614 625 patients in the NTDB were included in the study; 212 684 (34.6%) went to a non-home location. Patients with a non-home disposition compared to home had significantly higher age (69 ± 19.7 vs 48.3 ± 20.3) and ISS (11.2 ± 8.2 vs 8.2 ± 6.3); P < .001. Older age, female sex, higher ISS, comorbidities (cancer, cardiovascular, coagulopathy, diabetes, hepatic, neurological, psychiatric, renal, substance abuse), and Medicare insurance were independent predictors of non-home discharge. The logistic regression model’s AUC was 0.8; TDS achieved a correlation of 0.99 and performed similarly well on institutional data (n = 3161); AUC = 0.8. Conclusion We developed a score based on a large national trauma database that has acceptable performance on local institutions to predict patient discharge disposition at the time of admission. TDS can aid in early discharge preparation for likely-to-be non-home patients and may improve hospital efficiency.
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Affiliation(s)
- Mitchell Graham
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Pratik Parikh
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
- Department of Biomedical, Industrial and Human Factors Engineering, Wright State University, Dayton, OH, USA
| | - Sagar Hirpara
- Department of Biomedical, Industrial and Human Factors Engineering, Wright State University, Dayton, OH, USA
| | - Mary C. McCarthy
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Elliott R. Haut
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Armstrong Institute for Patient Safety and Quality (ERH), Johns Hopkins Medicine, Baltimore, MD, USA
- Department of Health Policy and Management (ERH), The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Priti P. Parikh
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
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Lifting the burden: State Medicaid expansion reduces financial risk for the injured. J Trauma Acute Care Surg 2020; 88:51-58. [PMID: 31524838 DOI: 10.1097/ta.0000000000002493] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Injuries are unanticipated and can be expensive to treat. Patients without sufficient health insurance are at risk for financial strain because of high out-of-pocket (OOP) health care costs relative to their income. We hypothesized that the 2014 Medicaid expansion (ME) in Washington (WA) state, which extended coverage to more than 600,000 WA residents, was associated with a reduction in financial risk among trauma patients. METHODS We analyzed all trauma patients aged 18 to 64 years admitted to the sole level 1 trauma center in WA from 2012 to 2017. We defined 2012 to 2013 as the prepolicy period and 2014 to 2017 as the postpolicy period. We used a multivariable linear regression model to evaluate for changes in length of stay, inpatient mortality, and discharge disposition. To evaluate for financial strain, we used WA state and US census data to estimate postsubsistence income and OOP expenses for our sample and then applied these two estimates to determine catastrophic health expenditure (CHE) risk as defined by the World Health Organization (OOP health expenses ≥40% of estimated household postsubsistence income). RESULTS A total of 16,801 trauma patients were included. After ME, the Medicaid coverage rate increased from 20.4% to 41.0%, and the uninsured rate decreased from 19.2% to 3.7% (p < 0.001 for both). There was no significant change in private insurance coverage. Medicaid expansion was not associated with significant changes in clinical outcomes or discharge disposition. Estimated CHE risk by payer was 81.4% for the uninsured, 25.9% for private insurance, and less than 0.1% for Medicaid. After ME, the risk of CHE for the policy-eligible sample fell from 26.4% to 14.0% (p < 0.01). CONCLUSION State ME led to an 80% reduction in the uninsured rate among patients admitted for injury, with an associated large reduction in the risk of CHE. However, privately insured patients were not fully protected from CHE. Additional research is needed to evaluate the impact of these policies on the financial viability of trauma centers. LEVEL OF EVIDENCE Economic analysis, level II.
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Abstract
BACKGROUND Trauma is the leading cause of death in the United States for persons under 44 years and the fourth leading cause of death in the elderly. Advancements in clinical care and standardization of treatment protocols have reduced 30-day trauma mortality to less than 4%. However, these improvements do not seem to correlate with long-term outcomes. Some reports have shown a greater than 20% mortality rate when looking at long-term outcomes. The aim of this study was to systematically review the incongruence between short- and long-term mortality for trauma patients. METHODS For this systematic review, we searched the Cochrane Library, EMBASE, Ovid Medline, Google Scholar, and Web of Science database to obtain relevant English, German, French, and Portuguese articles from 1965 to 2018. RESULTS Trauma patients have decreased long-term survival when compared to the general population and when compared with age-matched cohorts. Postdischarge trauma mortality is significantly higher (mean, 4.6% at 3-6 months, 15.8% at 2-3 years, 26.3% at 5-25 years) compared with controls (mean, 1.3%, 2.2%, and 15.6%, respectively). Patient comorbidities likely contribute to long-term trauma deaths. Trauma patients discharged to a skilled nursing facility have worse mortality compared with those discharged either to home or a rehabilitation center. In contrast to data available which illustrate that short-term mortality has improved, quality of evidence was not sufficient to determine if any improvements in long-term trauma mortality outcomes have also occurred. CONCLUSIONS The decreased short-term mortality observed in trauma patients does not appear correlated with decreased long-term mortality. The extent to which increased long-term trauma mortality is related to the initial traumatic insult-versus rising population age and comorbidity burden as well as suboptimal discharge location-requires further study. LEVEL OF EVIDENCE Systematic Review, level IV.
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Impact of Affordable Care Act-related insurance expansion policies on mortality and access to post-discharge care for trauma patients: an analysis of the National Trauma Data Bank. J Trauma Acute Care Surg 2020; 86:196-205. [PMID: 30694984 DOI: 10.1097/ta.0000000000002117] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Uninsured trauma patients have worse outcomes and worse access to post-discharge care that is critically important for recovery after injury. Little is known regarding the impact of the insurance coverage expansion policies of the Affordable Care Act (ACA), most notably state-level Medicaid expansion, on trauma patients. In this study, we examine the national impact of these policies on payer mix, inpatient mortality, and access to post-acute care for trauma patients. METHODS We used the 2011-2016 National Trauma Data Bank to evaluate for changes in insurance coverage among trauma patients 18-64 years old. Our pre-/post-expansion models defined 2011-2013 as the pre-policy period, 2015-2016 as the post-policy period, and 2014 as a washout year. To evaluate for policy-associated changes in inpatient mortality and discharge disposition among the policy-eligible sample, we leveraged multivariable linear regression techniques to adjust for year-to-year variation in patient demographics, injury characteristics, and facility traits. We then examined the relationship between the magnitude of facility-level reductions in uninsured patients and access to post-acute care after policy implementation. RESULTS We identified 1,656,469 patients meeting inclusion criteria between 2011 and 2016. The pre-policy uninsured rate of 23.4% fell by 5.9 percentage-points after coverage expansion (p < 0.001), with a corresponding 7.5 percentage-point increase in Medicaid coverage (p < 0.001). After policy implementation, there were no significant changes in inpatient mortality. However, there was a >30% relative increase in discharge to a post-acute care facility and a similar increase in discharge with home health services (p < 0.001 for both). The greatest gains in access to post-acute services were seen among facilities with the greatest reductions in their uninsured rate (p = 0.003). CONCLUSION ACA-related coverage expansion policies, most notably Medicaid expansion, were associated with a >25% reduction in the uninsured rate among non-elderly adult trauma patients. Although no immediate impact on inpatient mortality was seen, insurance coverage expansion was associated with a higher proportion of patients receiving critically important post-discharge care. LEVEL OF EVIDENCE Epidemiological, level III.
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Association of Insurance Status With Treatment and Outcomes in Pediatric Patients With Severe Traumatic Brain Injury. Crit Care Med 2020; 48:e584-e591. [PMID: 32427612 DOI: 10.1097/ccm.0000000000004398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether a health insurance disparity exists among pediatric patients with severe traumatic brain injury using the National Trauma Data Bank. DESIGN Retrospective cohort study. SETTING National Trauma Data Bank, a dataset containing more than 800 trauma centers in the United States. PATIENTS Pediatric patients (< 18 yr old) with a severe isolated traumatic brain injury were identified in the National Trauma Database (years 2007-2016). Isolated traumatic brain injury was defined as patients with a head Abbreviated Injury Scale score of 3+ and excluded those with another regional Abbreviated Injury Scale of 3+. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS Procedure codes were used to identify four primary treatment approaches combined into two classifications: craniotomy/craniectomy and external ventricular draining/intracranial pressure monitoring. Diagnostic criteria and procedure codes were used to identify condition at admission, including hypotension, Glasgow Coma Scale, mechanism and intent of injury, and Injury Severity Score. Children were propensity score matched using condition at admission and other characteristics to estimate multivariable logistic regression models to assess the associations among insurance status, treatment, and outcomes. Among the 12,449 identified patients, 91.0% (n = 11,326) had insurance and 9.0% (n = 1,123) were uninsured. Uninsured patients had worse condition at admission with higher rates of hypotension and higher Injury Severity Score, when compared with publicly and privately insured patients. After propensity score matching, having insurance was associated with a 32% (p = 0.001) and 54% (p < 0.001) increase in the odds of cranial procedures and monitor placement, respectively. Insurance coverage was associated with 25% lower odds of inpatient mortality (p < 0.001). CONCLUSIONS Compared with insured pediatric patients with a traumatic brain injury, uninsured patients were in worse condition at admission and received fewer interventional procedures with a greater odds of inpatient mortality. Equalizing outcomes for uninsured children following traumatic brain injury requires a greater understanding of the factors that lead to worse condition at admission and policies to address treatment disparities if causality can be identified.
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Zogg CK, Scott JW, Metcalfe D, Gluck AR, Curfman GD, Davis KA, Dimick JB, Haider AH. Association of Medicaid Expansion With Access to Rehabilitative Care in Adult Trauma Patients. JAMA Surg 2020; 154:402-411. [PMID: 30601888 DOI: 10.1001/jamasurg.2018.5177] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law's impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation. Objective To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act. Design, Setting, and Participants Quasi-experimental, difference-in-difference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states. Interventions/Exposure Policy implementation in January 2014. Main Outcomes and Measures Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation. Results A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity-, age-, and sex-based disparities in which patients use rehabilitation. Conclusions and relevance This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states.
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Affiliation(s)
- Cheryl K Zogg
- Yale School of Medicine, New Haven, Connecticut.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Solomon Center for Health Law and Policy, Yale Law School, New Haven, Connecticut
| | - John W Scott
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - David Metcalfe
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Abbe R Gluck
- Solomon Center for Health Law and Policy, Yale Law School, New Haven, Connecticut
| | - Gregory D Curfman
- Solomon Center for Health Law and Policy, Yale Law School, New Haven, Connecticut
| | | | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Kim DY, de Virgilio C. Medicaid Expansion Offers Hope for Improved Postinjury Rehabilitation Among the Underserved. JAMA Surg 2020; 154:412. [PMID: 30601872 DOI: 10.1001/jamasurg.2018.5178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Dennis Y Kim
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
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Liu C, Tsugawa Y, Weiser TG, Scott JW, Spain DA, Maggard-Gibbons M. Association of the US Affordable Care Act With Out-of-Pocket Spending and Catastrophic Health Expenditures Among Adult Patients With Traumatic Injury. JAMA Netw Open 2020; 3:e200157. [PMID: 32108892 PMCID: PMC7049078 DOI: 10.1001/jamanetworkopen.2020.0157] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
IMPORTANCE Trauma is an expensive and unpredictable source of out-of-pocket spending for American families. The Patient Protection and Affordable Care Act (ACA) sought to improve financial protection by expanding health insurance coverage, but its association with health care spending for patients with traumatic injury remains largely unknown. OBJECTIVE To evaluate the association of ACA implementation with out-of-pocket spending, premiums, and catastrophic health expenditures (CHE) among adult patients with traumatic injury. DESIGN, SETTING, AND PARTICIPANTS Data from a nationally representative sample of US adults aged 19 to 64 years who had a hospital stay or emergency department visit for a traumatic injury from January 2010 to December 2017 were analyzed using the Medical Expenditure Panel Survey. Multivariable generalized linear models were used to evaluate changes in spending after ACA implementation. Additionally, 4 income subgroups were evaluated based on ACA thresholds for program eligibility: lowest-income patients (earning 138% or less of the federal poverty level [FPL]), low-income patients (earning 139% to 250% of the FPL), middle-income patients (earning 251% to 400% of the FPL), and high-income patients (earning more than 400% of the FPL). Data were analyzed from February to December 2019. EXPOSURES Implementation of the ACA, beginning January 1, 2014. MAIN OUTCOMES AND MEASURES Out-of-pocket spending, premium spending, out-of-pocket plus premium spending, and likelihood of experiencing CHE, defined as out-of-pocket plus premium spending exceeding 19.5% of family income. RESULTS Of the 6288 included patients, 2995 (weighted percentage, 51.3%) were male, and the mean (SD) age was 41.4 (12.8) years. Implementation of the ACA was associated with 31% lower odds of CHE (adjusted odds ratio, 0.69; 95% CI, 0.54 to 0.87; P = .002). Changes were greatest in lowest-income patients, who experienced 30% lower out-of-pocket spending (adjusted percentage change, -30.4%; 95% CI, -46.6% to -9.4%; P = .01), 26% lower out-of-pocket plus premium spending (adjusted percentage change, -26.3%; 95% CI, -41.0% to -8.1%; P = .01), and 39% lower odds of CHE (adjusted odds ratio, 0.61; 95% CI, 0.44 to 0.84; P = .002). Low-income patients experienced decreased out-of-pocket spending and out-of-pocket plus premium spending but no changes in CHE, while middle-income and high-income patients experienced no significant changes in any spending outcome. In the post-ACA period, 1 in 11 of all patients with traumatic injury and 1 in 5 with the lowest incomes continued to experience CHE each year. CONCLUSIONS AND RELEVANCE Implementation of the ACA was associated with improved financial protection for US adults with traumatic injury, especially lowest-income individuals targeted by the law's Medicaid expansions. Despite these gains, injured patients remain at risk of financial strain.
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Affiliation(s)
- Charles Liu
- Department of Surgery, Stanford University, Stanford, California
- National Clinician Scholars Program, University of California, Los Angeles
- VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, University of California, Los Angeles
- Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles
| | - Thomas G. Weiser
- Department of Surgery, Stanford University, Stanford, California
| | - John W. Scott
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor
| | - David A. Spain
- Department of Surgery, Stanford University, Stanford, California
| | - Melinda Maggard-Gibbons
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles
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Impact of the Affordable Care Act on trauma and emergency general surgery: An Eastern Association for the Surgery of Trauma systematic review and meta-analysis. J Trauma Acute Care Surg 2020; 87:491-501. [PMID: 31095067 DOI: 10.1097/ta.0000000000002368] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma and emergency general surgery (EGS) patients who are uninsured have worse outcomes as compared with insured patients. Partially modeled after the 2006 Massachusetts Healthcare Reform (MHR), the Patient Protection and Affordable Care Act was passed in 2010 with the goal of expanding health insurance coverage, primarily through state-based Medicaid expansion (ME). We evaluated the impact of ME and MHR on outcomes for trauma patients, EGS patients, and trauma systems. METHODS This study was approved by the Eastern Association for the Surgery of Trauma Guidelines Committee. Using Grading of Recommendations Assessment, Development and Evaluation methodology, we defined three populations of interest (trauma patients, EGS patients, and trauma systems) and identified the critical outcomes (mortality, access to care, change in insurance status, reimbursement, funding). We performed a systematic review of the literature. Random effect meta-analyses and meta-regression analyses were calculated for outcomes with sufficient data. RESULTS From 4,593 citations, we found 18 studies addressing all seven predefined outcomes of interest for trauma patients, three studies addressing six of seven outcomes for EGS patients, and three studies addressing three of eight outcomes for trauma systems. On meta-analysis, trauma patients were less likely to be uninsured after ME or MHR (odds ratio, 0.49; 95% confidence interval, 0.37-0.66). These coverage expansion policies were not associated with a change in the odds of inpatient mortality for trauma (odds ratio, 0.96; 95% confidence interval, 0.88-1.05). Emergency general surgery patients also experienced a significant insurance coverage gains and no change in inpatient mortality. Insurance expansion was often associated with increased access to postacute care at discharge. The evidence for trauma systems was heterogeneous. CONCLUSION Given the evidence quality, we conditionally recommend ME/MHR to improve insurance coverage and access to postacute care for trauma and EGS patients. We have no specific recommendation with respect to the impact of ME/MHR on trauma systems. Additional research into these questions is needed. LEVEL OF EVIDENCE Review, Economic/Decision, level III.
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Spruce MW, Bowman JA, Wilson AJ, Galante JM. Improving Incidental Finding Documentation in Trauma Patients Amidst Poor Access to Follow-up Care. J Surg Res 2019; 248:62-68. [PMID: 31865160 DOI: 10.1016/j.jss.2019.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/21/2019] [Accepted: 11/09/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Incidental findings (IFs) are common among injured patients and create a complex problem with no standardized solution. MATERIALS AND METHODS This is a retrospective review of adult trauma patients admitted to a level I trauma center from January to May 2017. IFs from abdominal, chest, and neck imaging were categorized based on previously published guidelines focused on clinically significant IFs. Patient demographics related to access to care were collected. Outcome measures included documentation and patient notification of IFs. A univariate analysis was performed to identify characteristics that were associated with these outcomes. RESULTS Of 1671 patients, 682 met inclusion criteria, and 418 (61.3%) had any IF based on the a priori categorization scheme. In total, 67 (9.8%) were homeless, 58 (8.5%) had no health insurance, and 115 (16.9%) had no established primary care provider prior to admission. Documentation of IFs was included in discharge summaries and instructions 76.5% and 40.2% of the time, respectively. Physicians were statistically more likely to appropriately document IFs when radiologists provided specific recommendations. Transfer to another hospital service prior to discharge and discharge to another acute care facility were associated with reduced rates of successful documentation. No factors significantly affected documentation of patient notification. CONCLUSIONS Trauma patients are at risk for poor access to follow-up care of IFs. Expanding IF-specific guidelines, collaborating with radiologists to facilitate their inclusion in reports, and ensuring that IFs are part of patient hand-offs could provide systematic methods of improving their documentation.
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Affiliation(s)
- Marguerite W Spruce
- Department of Surgery, University of California Davis, Sacramento, California; Department of Surgery, David Grant USAF Medical Center, Fairfield, California.
| | - Jessica A Bowman
- Department of Surgery, University of California Davis, Sacramento, California
| | - Alice J Wilson
- School of Medicine, University of California Davis, Sacramento, California
| | - Joseph M Galante
- Department of Surgery, University of California Davis, Sacramento, California
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Bartley CN, Atwell K, Cairns B, Charles A. Racial and Ethnic Disparities in Discharge to Rehabilitation Following Burn Injury. J Burn Care Res 2019; 40:143-147. [PMID: 30698732 DOI: 10.1093/jbcr/irz001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Racial and ethnic disparities in access to inpatient rehabilitation have been previously described for various injury groups; however, no studies have evaluated whether such disparities exist among burn patients. Their aim was to determine if racial disparities in discharge destination (inpatient rehabilitation, skilled nursing facility, home with home health, or home) following burn injury existed in this single-institution study. A retrospective analysis of all adult burn patients admitted to UNC Jaycee Burn Center from 2002 to 2012 was conducted. Patient characteristics included age, gender, burn mechanism, insurance status, percentage total body surface area (%TBSA) burned, presence of inhalation injury, and hospital length of stay. Patients were categorized into one of three mutually exclusive racial or ethnic groups: White, Hispanic, or Black. Propensity score weighting followed by ordered logistic regression was performed in the analytical sample and in a subgroup analysis of patients with severe burns (TBSA > 20%). For analysis, 4198 patients were included: 2661 White, 340 Hispanic, and 1197 Black. Propensity weighting resulted in covariate balance among racial groups. Black patients (OR: 1.58, 95% CI: 1.23-2.03; P < .001) were more likely than Whites to be discharged to a higher level of rehabilitation, whereas Hispanics were less likely (OR: 0.78, 95% CI: 0.38-1.58; P = .448). In their subgroup analysis, Black (OR: 1.88, 95% CI: 1.07-3.28; P = .026) and Hispanic (OR: 1.53, 95% CI: 0.31-7.51; P = .603) patients were more likely to discharge to a higher level of rehabilitation than White patients. Racial and ethnic disparities in discharge destination to a higher level of rehabilitative services among burn-injured patients exist particularly for Hispanic patients but not for Black or White burn patient groups. Further studies are needed to elucidate the potential sources of these disparities specifically for Hispanic patients.
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Affiliation(s)
- Colleen N Bartley
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, Chapel Hill, North Carolina
| | - Kenisha Atwell
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, Chapel Hill, North Carolina
| | - Bruce Cairns
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, Chapel Hill, North Carolina
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, Chapel Hill, North Carolina
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Joseph B, Kulvatunyou N, Friese RS, Rhee P, O'Keeffe T, Branco BC, Mobily M, Wynne JL, Tang AL. Does Money Matter? Relationship between Household Income and Mortality after Trauma. ACTA ACUST UNITED AC 2019. [DOI: 10.5005/jp-journals-10030-1245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Predictors of Discharge Destination From Acute Care in Patients With Traumatic Brain Injury: A Systematic Review. J Head Trauma Rehabil 2019; 34:52-64. [DOI: 10.1097/htr.0000000000000403] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Factors Associated with Discharge to a Skilled Nursing Facility after Transcatheter Aortic Valve Replacement Surgery. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 16:ijerph16010073. [PMID: 30597877 PMCID: PMC6339195 DOI: 10.3390/ijerph16010073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 12/18/2018] [Accepted: 12/25/2018] [Indexed: 12/24/2022]
Abstract
An assumption regarding transcatheter aortic valve replacement (TAVR), a minimally invasive procedure for treating aortic stenosis, is that patients remain at, or near baseline and soon return to their presurgical home to resume activities of daily living. However, this does not consistently occur. The purpose of this study was to identify preoperative factors that optimally predict discharge to a skilled nursing facility (SNF) after TAVR. Delineation of these conditions is an important step in developing a risk stratification model to assist in making informed decisions. Data was extracted from the American College of Cardiology (ACC) transcatheter valve therapy (TVT) registry and the Society of Thoracic Surgeons (STS) database on 285 patients discharged from 2012⁻2017 at a tertiary referral heart institute located in the southeastern region of the United States. An analysis of assessment, clinical and demographic variables was used to estimate relative risk (RR) of discharge to a SNF. The majority of participants were female (55%) and white (84%), with a median age of 82 years (interquartile range = 9). Approximately 27% (n = 77) were discharged to a SNF. Age > 75 years (RR = 2.3, p = 0.0026), female (RR = 1.6, p = 0.019), 5-meter walk test (5MWT) >7 s (RR = 2.0, p = 0.0002) and not using home oxygen (RR = 2.9, p = 0.0084) were identified as independent predictive factors for discharge to a SNF. We report a parsimonious risk-stratification model that estimates the probability of being discharged to a SNF following TAVR. Our findings will facilitate making informed treatment decisions regarding this older patient population.
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The Affordable Care Act’s Effect on Discharge Disposition of Racial Minority Trauma Patients in the United States. J Racial Ethn Health Disparities 2018; 6:427-435. [DOI: 10.1007/s40615-018-00540-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 10/23/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
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Haines KL, Nguyen BP, Vatsaas C, Alger A, Brooks K, Agarwal SK. Socioeconomic Status Affects Outcomes After Severity-Stratified Traumatic Brain Injury. J Surg Res 2018; 235:131-140. [PMID: 30691786 DOI: 10.1016/j.jss.2018.09.072] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/10/2018] [Accepted: 09/24/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Socioeconomic status (SES) and race have been shown to increase the incidence of being afflicted by a traumatic brain injury (TBI) resulting in worse posthospitalization outcomes. The goal of this study was to determine the effect disparities have on in-hospital mortality, discharge to inpatient rehabilitation, hospital length of stay (LOS), and TBI procedures performed stratified by severity of TBI. METHODS This was a retrospective cohort study of patients with closed head injuries using the National Trauma Data Bank (2012-2015). Multivariate logistic/linear regression models were created to determine the impact of race and insurance status in groups graded by head Abbreviated Injury Scale (AIS). RESULTS We analyzed 131,461 TBI patients from NTDB. Uninsured patients experienced greater mortality at an AIS of 5 (odds ratio [OR] = 1.052, P = 0.001). Uninsured patients had a decreased likelihood of being discharged to inpatient rehabilitation with an increasing AIS beginning from an AIS of 2 (OR = 0.987, P = 0.008) to an AIS of 5 (OR = 0.879, P < 0.001). Black patients had an increased LOS as their AIS increased from an AIS of 2 (0.153 d, P < 0.001) to 5 (0.984 d, P < 0.001) with the largest discrepancy in LOS occurring at an AIS of 5. CONCLUSIONS Disparities in race and SES are associated with differences in mortality, LOS, and discharge to inpatient rehabilitation. Patients with more severe TBI have the greatest divergence in treatment and outcome when stratified by race and ethnicity as well as SES.
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Affiliation(s)
- Krista L Haines
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Benjamin P Nguyen
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Cory Vatsaas
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Amy Alger
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Kelli Brooks
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Suresh K Agarwal
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Examining Injustice Appraisals in a Racially Diverse Sample of Individuals With Chronic Low Back Pain. THE JOURNAL OF PAIN 2018; 20:83-96. [PMID: 30179671 DOI: 10.1016/j.jpain.2018.08.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 07/26/2018] [Accepted: 08/14/2018] [Indexed: 12/18/2022]
Abstract
Injustice perception has emerged as a risk factor for problematic musculoskeletal pain outcomes. Despite the prevalence and impact of chronic low back pain (CLBP), no study has addressed injustice appraisals specifically among individuals with CLBP. In addition, despite racial/ethnic disparities in pain, existing injustice research has relied almost exclusively on white/Caucasian participant samples. The current study examined the associations between perceived injustice and pain, disability, and depression in a diverse community sample of individuals with CLBP (N = 137) -51 (37.2%) white, 43 (31.4%) Hispanic, 43 (31.4%) black or African American). Anger variables were tested as potential mediators of these relationships. Controlling for demographic and pain-related covariates, perceived injustice accounted for unique variance in self-reported depression and disability outcomes, but not pain intensity. State and trait anger, and anger inhibition mediated the association between perceived injustice and depression; no additional mediation by anger was observed. Significant racial differences were also noted. Compared with white and Hispanic participants, black participants reported higher levels of perceived injustice related to CLBP, as well as higher depression and pain-related disability. Black participants also reported higher pain intensity than white participants. Current findings provide initial evidence regarding the role of injustice perception specifically in the context of CLBP and within a racially diverse participant sample. Results highlight the need for greater diversity within injustice and CLBP research as well as research regarding socially informed antecedents of injustice appraisals. Perspective: Perceived injustice predicted worse outcomes in CLBP, with effects partially mediated by anger. Black participants reported worse pain outcomes and higher injustice perception than their white or Hispanic counterparts. Given racial inequities within broader health and pain-specific outcomes, this topic is critical for CLBP and perceived injustice research.
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Berg GM, Searight M, Sorell R, Lee FA, Hervey AM, Harrison P. Payer Source Associated with Disparities in Procedural, but Not Surgical, Care in a Trauma Population. Am Surg 2018. [DOI: 10.1177/000313481808400856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Trauma centers are legally bound by Emergency Medical Treatment and Active Labor Act to provide equal treatment to trauma patients, regardless of payer source. However, evidence has suggested that disparities in trauma care exist. This study investigated the relationships between payer source and procedures (total, diagnostic, and surgical) and the number of medical consults in an adult trauma population. This is a 10-year retrospective trauma registry study at a Level I trauma facility. Payer source of adult trauma patients was identified, demographics and variables associated with trauma outcomes were abstracted, and multivariate logistic regression tests were used to determine statistical differences in the number of procedures and medical consults. Of the 12,870 records analyzed, 69.1 per cent of patients were commercially insured, 21.2 per cent were uninsured, and 9.6 per cent had Medicaid. After controlling for patient- and injury-related variables, the commercially insured received more total procedures (4.30) than the uninsured (3.35) or those with Medicaid (3.34), and more diagnostic (2.59) procedures than the uninsured (2.03) or those with Medicaid (2.04). There was not a difference in the number of surgical procedures or medical consults among payer sources. This study noted that disparities (measured by the number of procedures received) compared by payer source existed in the care of trauma patients. However, for medical consults and definitive care (measured by surgical procedures), disparities were not observed. Future research should focus on secondary factors that influence levels of care such as patient-level factors (health literacy) and trauma program policies.
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Affiliation(s)
- Gina M. Berg
- Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, Kansas
- Department of Trauma Services, Wesley Healthcare, Wichita, Kansas
| | - Maggie Searight
- Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, Kansas
| | - Ryan Sorell
- Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, Kansas
| | - Felecia A. Lee
- Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, Kansas
| | - Ashley M. Hervey
- Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, Kansas
| | - Paul Harrison
- Department of Trauma Services, Wesley Healthcare, Wichita, Kansas
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Trauma-induced insurance instability: Variation in insurance coverage for patients who experience readmission after injury. J Trauma Acute Care Surg 2018; 84:876-884. [DOI: 10.1097/ta.0000000000001832] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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James MK, Robitsek RJ, Saghir SM, Gentile PA, Ramos M, Perez F. Clinical and non-clinical factors that predict discharge disposition after a fall. Injury 2018; 49:975-982. [PMID: 29463382 DOI: 10.1016/j.injury.2018.02.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/26/2018] [Accepted: 02/09/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Falls can result in injuries that require rehabilitation and long-term care after hospital discharge. Identifying factors that contribute to prediction of discharge disposition is crucial for efficient resource utilization and reducing cost. Several factors may influence discharge location after hospitalization for a fall. The aim of this study was to examine clinical and non-clinical factors that may predict discharge disposition after a fall. We hypothesized that age, injury type, insurance type, and functional status would affect discharge location. METHODS This two-year retrospective study was performed at an urban, adult level-1 trauma center. Fall patients who were discharged home or to a facility after hospital admission were included in the study. Data was obtained from the trauma registry and electronic medical records. Logistic regression modeling was used to assess independent predictors. RESULTS A total of 1,121 fallers were included in the study. 621 (55.4%) were discharged home and 500 (44.6%) to inpatient rehabilitation (IRF)/skilled nursing facility (SNF). The median age was 64 years (IQR: 49-79) and 48.4% (543) were male. The median length of hospital stay was 5 days (IQR: 2.5-8). Increasing age (p < 0.001), length of stay in the ICU (p < 0.001), injury severity (p < 0.001), number of comorbidities (p = 0.038), having Medicare insurance (p = 0.025), having a fracture at any body region (p < 0.001), and ambulation status (p = 0.025) significantly increased the odds of being discharged to IRF/SNF compared to home. The removal of injury severity score and ICU length of stay from the "late/regular discharge" model, to create an "early discharge" model, decreased the accuracy of the prediction rate from 78.5% to 74.9% (p < 0.001). CONCLUSION A combination of demographic, clinical, social, economic, and functional factors can together predict discharge disposition after a fall. The majority of these factors can be assessed early in the hospital stay, which may facilitate a timely discharge plan and shorter stays in the hospital.
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Affiliation(s)
- Melissa K James
- Department of Surgery, Jamaica Hospital Medical Center, Jamaica, New York, USA.
| | - R Jonathan Robitsek
- Department of Surgery, Jamaica Hospital Medical Center, Jamaica, New York, USA.
| | - Syed M Saghir
- Department of Medicine, University of Nevada, Las Vegas, Nevada, USA.
| | - Patricia A Gentile
- Departement of Occupational Therapy, NYU Steinhardt School of Culture, Education and Human Development, New York, NY, USA.
| | - Marylin Ramos
- Department of Rehabilitation, Jamaica Hospital Medical Center, Jamaica, New York, USA.
| | - Frances Perez
- Department of Case Management, Jamaica Hospital Medical Center, Jamaica, New York, USA.
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Effects of Medicaid expansion on disparities in trauma care and outcomes in young adults. J Surg Res 2018; 228:42-53. [PMID: 29907229 DOI: 10.1016/j.jss.2018.02.058] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/08/2018] [Accepted: 02/27/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Racial/ethnic and socioeconomic disparities in trauma care and outcomes among young adults are well documented. As the Patient Protection and Affordable Care Act Medicaid expansion has increased insurance coverage among young adults, we aimed to investigate its impact on disparities in insurance coverage and outcomes among hospitalized young adult trauma patients. MATERIALS AND METHODS We used the healthcare cost and utilization project state inpatient databases to examine changes in insurance coverage and risk-adjusted outcomes from before (2012-2013) to after (2014) Medicaid expansion among young adults (age 19-44) hospitalized for injury across 11 Medicaid expansion states. Changes were compared across racial/ethnic and community-level income groups. We also compared changes in disparities between three expansion and three nonexpansion states in the US south. RESULTS In the first year of Medicaid expansion, non-Hispanic black trauma patients experienced a large decrease in uninsurance (34.3%-14.2%, P < 0.01), reducing the disparity in uninsurance between non-Hispanic black and non-Hispanic white patients (P < 0.05). There were no differences across racial/ethnic groups in changes in in-hospital mortality, failure to rescue, discharge to rehabilitation, or 30-d unplanned readmissions. Socioeconomic disparities in discharge to rehabilitation decreased (1.63% versus 0.06% increase among patients from the lowest and highest income communities, P < 0.05). In contrast, in the selected southern states, Medicaid expansion was associated with the introduction of a disparity in discharge to inpatient rehabilitation between Hispanics and non-Hispanic whites. CONCLUSIONS Medicaid expansion, in its first year, decreased racial and socioeconomic disparities in uninsurance and socioeconomic disparities in access to rehabilitation.
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Dexter F, Epstein RH. Reductions in Average Lengths of Stays for Surgical Procedures Between the 2008 and 2014 United States National Inpatient Samples Were Not Associated With Greater Incidences of Use of Postacute Care Facilities. Anesth Analg 2018; 126:983-987. [DOI: 10.1213/ane.0000000000002405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Equal Access Is Quality: an Update on the State of Disparities Research in Trauma. CURRENT TRAUMA REPORTS 2018. [DOI: 10.1007/s40719-018-0114-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Dodson JA, Williams MR, Cohen DJ, Manandhar P, Vemulapalli S, Blaum C, Zhong H, Rumsfeld JS, Hochman JS. Hospital Practice of Direct-Home Discharge and 30-Day Readmission After Transcatheter Aortic Valve Replacement in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) Registry. J Am Heart Assoc 2017; 6:JAHA.117.006127. [PMID: 28862964 PMCID: PMC5586454 DOI: 10.1161/jaha.117.006127] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Nearly 17% of patients are readmitted within 30 days of discharge after transcatheter aortic valve replacement. Selected patients are discharged to skilled nursing facilities, yet the association between a hospital's practice to discharge home versus to skilled nursing facilities, and readmission remains unclear. Methods and Results The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) Registry was used to evaluate readmissions among patients undergoing transcatheter aortic valve replacement (2011‐2015). Hospitals were divided into quartiles (Q1‐Q4) based on the percentage of patients discharged directly home. We assessed patient and hospital level characteristics and used hierarchical logistic regression to analyze the association of discharge disposition with 30‐day readmission. Our cohort included 18 568 transcatheter aortic valve replacement patients at 329 US hospitals, of whom 69% were discharged directly home. Hospitals in the highest quartile of direct home discharge (Q4) compared with hospitals in the lowest (Q1) were more likely to use femoral access (75.2% versus 60.1%, P<0.001), had fewer patients receiving transfusion (26.4% versus 40.9%, P<0.001), and were more likely to be located in the Southern United States (48.8% versus 18.3%, P<0.001). Median 30‐day readmission rate was 17.9%. There was no significant difference in 30‐day readmissions among quartiles (P=0.14), even after multivariable adjustment (odds ratio Q4 versus Q1=0.89, 95%CI 0.76‐1.04; P=0.15). Factors most strongly associated with 30‐day readmission were glomerular filtration rate, in‐hospital stroke or transient ischemic attack, and nonfemoral access. Conclusions There was no statistically significant association between hospital practice of direct home discharge post–transcatheter aortic valve replacement and 30‐day readmission. Further research is needed to understand regional variations and optimum strategies for postdischarge care.
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Affiliation(s)
- John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY .,Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, NY
| | - Mathew R Williams
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY.,Department of Cardiac Surgery, New York University School of Medicine, New York, NY
| | - David J Cohen
- Saint Luke's Mid America Heart Institute, Kansas City, MO.,University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Pratik Manandhar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Caroline Blaum
- Division of Geriatrics, Department of Medicine, New York University School of Medicine, New York, NY
| | - Hua Zhong
- Division of Epidemiology, Department of Population Health, New York University School of Medicine, New York, NY
| | | | - Judith S Hochman
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY
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Ulloa JG, Woo K, Tseng CH, Maggard-Gibbons M, Rigberg D. Access to Posthospitalization Acute Care Facilities is Associated with Payer Status for Open Abdominal Aortic Repair and Open Lower Extremity Revascularization in the Vascular Quality Initiative. Ann Vasc Surg 2017; 42:1-10. [DOI: 10.1016/j.avsg.2016.10.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 09/05/2016] [Accepted: 10/24/2016] [Indexed: 11/16/2022]
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Casp AJ, Wells J, Holzgrefe R, Weiss D, Kahler D, Yarboro SR. Evaluation of Orthopedic Trauma Surgery Follow-up and Impact of a Routine Callback Program. Orthopedics 2017; 40:e312-e316. [PMID: 28056157 DOI: 10.3928/01477447-20161229-01] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 12/02/2016] [Indexed: 02/03/2023]
Abstract
A high rate of patients lost to follow-up is a common problem in orthopedic trauma surgery. This adversely affects the ability to produce accurate clinical outcomes research. The purpose of this project was to (1) evaluate the rate of loss to follow-up at an academic level I trauma center; (2) identify the patient-reported reasons for loss to follow-up; and (3) evaluate the efficacy of a routine patient callback program. All patients who underwent surgery in the orthopedic trauma division of the University of Virginia Medical Center from April 1, 2014, to September 30, 2014, and did not complete their postoperative clinic follow-up were analyzed. The characteristics of these patients were evaluated, and the primary reason for not completing the recommended follow-up was identified. All patients were then offered additional orthopedic follow-up at the time of contact. Of the 480 patients who met the inclusion criteria, 41 (8.5%) failed to complete the recommended postoperative follow-up course. The most common reason for being lost to follow-up was feeling well and not having the need to be seen (46.3%). Only 6 (14.6%) of the 41 patients requested follow-up care at the time of contact. The lost to follow-up rate in this study, 8.5%, was considerably lower than that previously reported, but patient characteristics were consistent with those of prior studies on this subject. The low lost to follow-up rate may reflect a difference in geographic location or patient population. The patient callback program had a low yield of patients requesting additional follow-up after being contacted. [Orthopedics. 2017; 40(2):e312-e316.].
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Medford-Davis LN, Fonarow GC, Bhatt DL, Xu H, Smith EE, Suter R, Peterson ED, Xian Y, Matsouaka RA, Schwamm LH. Impact of Insurance Status on Outcomes and Use of Rehabilitation Services in Acute Ischemic Stroke: Findings From Get With The Guidelines-Stroke. J Am Heart Assoc 2016; 5:JAHA.116.004282. [PMID: 27930356 PMCID: PMC5210352 DOI: 10.1161/jaha.116.004282] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Insurance status affects access to care, which may affect health outcomes. The objective was to determine whether patients without insurance or with government‐sponsored insurance had worse quality of care or in‐hospital outcomes in acute ischemic stroke. Methods and Results Multivariable logistic regressions with generalized estimating equations stratified by age under or at least 65 years were adjusted for patient demographics and comorbidities, presenting factors, and hospital characteristics to determine differences in in‐hospital mortality and postdischarge destination. We included 589 320 ischemic stroke patients treated at 1604 US hospitals participating in the Get With The Guidelines‐Stroke program between 2012 and 2015. Uninsured patients with hypertension, high cholesterol, or diabetes mellitus were less likely to be taking appropriate control medications prior to stroke, to use an ambulance to arrive to the ED, or to arrive early after symptom onset. Even after adjustment, the uninsured were more likely than the privately insured to die in the hospital (<65 years, OR 1.33 [95% CI 1.22‐1.45]; ≥65 years OR 1.54 [95% CI 1.34‐1.75]), and among survivors, were less likely to go to inpatient rehab (<65 OR 0.63 [95% CI 0.6‐0.67]; ≥65 OR 0.56 [95% CI 0.5‐0.63]). In contrast, patients with Medicare and Medicaid were more likely to be discharged to a Skilled Nursing Facility (<65 years OR 2.08 [CI 1.96‐2.2]; OR 2.01 [95% CI 1.91‐2.13]; ≥65 years OR 1.1 [95% CI 1.07‐1.13]; OR 1.41 [95% CI 1.35‐1.46]). Conclusions Preventative care prior to ischemic stroke, time to presentation for acute treatment, access to rehabilitation, and in‐hospital mortality differ by patient insurance status.
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Affiliation(s)
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA
| | - Deepak L Bhatt
- Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Robert Suter
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.,Department of Cardiology, Duke University Medical Center, Durham, NC
| | - Ying Xian
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.,Department of Neurology, Duke University Medical Center, Durham, NC
| | - Roland A Matsouaka
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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McQuistion K, Zens T, Jung HS, Beems M, Leverson G, Liepert A, Scarborough J, Agarwal S. Insurance status and race affect treatment and outcome of traumatic brain injury. J Surg Res 2016; 205:261-271. [DOI: 10.1016/j.jss.2016.06.087] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/05/2016] [Accepted: 06/26/2016] [Indexed: 10/21/2022]
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