Association between implementation of a coordinated care pathway in idiopathic scoliosis patients and a reduction in perioperative outcome disparities

A Longitudinal Multivariable Analysis: State Policies and Opioid Dispensing in Medicare Beneficiaries Undergoing Surgery

BACKGROUND

States have implemented policies to decrease clinically unnecessary opioid prescribing, but few studies have examined how state policies affect opioid dispensing rate trends for surgical patients.

OBJECTIVE

To examine trends in the perioperative opioid dispensing rates for fee-for-service Medicare beneficiaries and the effects of select state policies.

DESIGN AND PARTICIPANTS

A retrospective cohort study using 2006 to 2018 Medicare claims data for individuals undergoing surgical procedures for which opioid analgesic treatment is common.

EXPOSURES

State policies mandating prescription drug monitoring program (PDMP; PDMP policies) use, initial opioid prescription duration limit (duration limit policies), and mandated continuing medical education (CME; CME pain policies) on pain management.

MAIN MEASURES

Opioid dispensing rates, days' supply, and the daily morphine milligram equivalent dose (MMED).

KEY RESULTS

The percentage of Medicare beneficiaries dispensed opioids in the perioperative period increased from 2007 to 2018; MMED and days' supply decreased over the same period, with significant variation by age, sex, and race. None of the three state policies affected the likelihood of Medicare beneficiaries being dispensed perioperative opioids. However, CME pain policies and duration limit policies were associated with decreased days' supply and decreased MMED in the several years following implementation, respectively.

CONCLUSION

While we observed a slight increase in the rate of Medicare beneficiaries dispensed opioids perioperatively and a substantial decrease in MMED and days' supply for those receiving opioids, state policies examined had relatively modest effects on the main measures. Our findings suggest that these state policies may have a limited impact on opioid dispensing for a patient population that is commonly dispensed opioid analgesics to help control surgical pain, and as a result may have little direct effect on clinical outcomes for this population. Changes in opioid dispensing for this population may be the result of broader societal trends than such state policies.

Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence

Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.

Surgical Care for Racial and Ethnic Minorities and Interventions to Address Inequities: A Narrative Review

OBJECTIVE

Racial and ethnic inequities in surgical care in the United States are well documented. Less is understood about evidence-based interventions that improve surgical care and reduce or eliminate inequities. In this review, we discuss effective patient, surgeon, community, health care system, policy, and multi-level interventions to reduce inequities and identifying gaps in intervention-based research.

BACKGROUND

Evidenced-based interventions to reduce racial and ethnic inequities in surgical care are key to achieving surgical equity. Surgeons, surgical trainees, researchers, and policy makers should be aware of the evidence-based interventions known to reduce racial and ethnic disparities in surgical care for prioritization of resource allocation and implementation. Future research is needed to assess interventions effectiveness in the reduction of disparities and patient-reported measures.

METHODS

We searched PubMed database for English-language studies published from January 2012 through June 2022 to assess interventions to reduce or eliminate racial and ethnic disparities in surgical care. A narrative review of existing literature was performed identifying interventions that have been associated with reduction in racial and ethnic disparities in surgical care.

RESULTS AND CONCLUSIONS

Achieving surgical equity will require implementing evidenced-based interventions to improve quality for racial and ethnic minorities. Moving beyond description toward elimination of racial and ethnic inequities in surgical care will require prioritizing funding of intervention-based research, utilization of implementation science and community based-participatory research methodology, and principles of learning health systems.

What's New in Pediatric Orthopaedic Health Care Disparities?

BACKGROUND

Health care disparities are prevalent within pediatric orthopaedics in the United States. Social determinants of health, such as income, race, social deprivation, place of residence, and parental involvement, all play a role in unequal access to care and disparate outcomes. Although there has been some effort to promote health equity both within pediatric orthopaedics and the US health care system altogether, disparities persist. In this review, we aim to identify major sources of inequality and propose solutions to achieve equitable care in the future.

METHODS

We searched the PubMed database for papers addressing disparities in pediatric orthopaedics published between 2016 and 2021, yielding 283 papers.

RESULTS

A total of 36 papers were selected for review based upon new findings. Insurance status, race, and social deprivation are directly linked to poorer access to care, often resulting in a delay in presentation, time to diagnostic imaging, and surgery. Although these disparities pervade various conditions within pediatric orthopaedics, they have most frequently been described in anterior cruciate ligament/meniscal repairs, tibial spine fractures, adolescent idiopathic scoliosis, and upper extremity conditions. Treatment outcomes also differ based on insurance status and socioeconomic status. Several studies demonstrated longer hospital stays and higher complication rates in Black patients versus White patients. Patients with public insurance were also found to have worse pain and function scores, longer recoveries, and lower post-treatment follow-up rates. These disparate outcomes are, in part, a response to delayed access to care.

CONCLUSIONS

Greater attention paid to health care disparities over the past several years has enabled progress toward achieving equitable pediatric orthopaedic care. However, delays in access to pediatric orthopaedic care among uninsured/publicly insured, and/or socially deprived individuals remain and consequently, so do differences in post-treatment outcomes. Reducing barriers to care, such as insurance status, transportation and health literacy, and promoting education among patients and parents, could help health care access become more equitable.

LEVEL OF EVIDENCE

Level IV-narrative review.