Clinician-to-clinician connectedness and access to gastric cancer surgery at National Cancer Institute-designated cancer centers

BACKGROUND

For patients with gastric cancer, the pathway from primary care (PC) clinician to gastroenterologist to cancer specialist (medical oncologist or surgeons) is referral dependent. The impact of clinician connectedness on disparities in quality gastric cancer care, such as at National Cancer Institute-designated cancer centers (NCI-CC), remains underexplored. This study evaluated how clinician connectedness influences access to gastrectomy at NCI-CC.

METHODS

Maryland's All-Payer Claims Database was used to evaluate 667 patients who underwent gastrectomy for cancer from 2013 to 2018. Two separate referral linkages, defined as ≥9 shared patients, were examined: (1) PC clinicians to gastroenterologists at NCI-CC and (2) gastroenterologists to cancer specialists at NCI-CC. Multiple logistic regression models determined associations between referral linkages and odds of undergoing gastrectomy at NCI-CC.

RESULTS

Only 15% of gastrectomies were performed at NCI-CC. Patients of gastroenterologists with referral links to cancer specialists at NCI-CC were more likely to be <65 years, male, White, and privately insured. Every additional referral link between PC clinician and gastroenterologist at NCI-CC and between gastroenterologist and cancer specialist at NCI-CC increased the odds of gastrectomy at NCI-CC by 71% and 26%, respectively. Black patients had half the odds as White patients in receiving gastrectomy at NCI-CC; however, adjusting for covariates including clinician-to-clinician connectedness attenuated this observation.

CONCLUSION

Patients of clinicians with low connectedness and Black patients are less likely to receive gastrectomy at NCI-CC. Enhancing clinician connectedness is necessary to address disparities in cancer care. These results are relevant to policy makers, clinicians, and patient advocates striving for health equity.

Socioeconomic and regional variations in repair modality for ruptured abdominal aortic aneurysms

BACKGROUND

Previous studies report that patients of racial/ethnic minorities more frequently present with ruptured abdominal aortic aneurysms (rAAAs) than their counterparts. The distribution of rAAA treatment modality, whether open aneurysm repair (OAR) or endovascular aneurysm repair (EVAR), by race/ethnicity classification remains uncertain. This study aims to investigate disparities, as represented by race/ethnic classification, median income, and insurance status, in the management of rAAA in a national cohort.

METHODS

We conducted a retrospective analysis of patients admitted with rAAA managed with either OAR or EVAR from 2002 to 2020 using the National Inpatient Sample, comparing repair type by race/ethnicity group. Multilevel mixed effects logistic regression models, adjusted for patient- and system-level factors, were used to calculate difference in use of OAR or EVAR dependent on race/ethnicity classification.

RESULTS

We identified 10,788 admissions for rAAA repairs, of which 9506 (88.1%) were White, 605 (5.6%) were Black, 424 (3.9%) were Hispanic, and 253 (2.4%) were Asian/Native American. Asians/Native Americans underwent the highest frequency of OAR as compared with EVAR (61.7% vs 38.3%). In the adjusted model, there was no statistically significant difference in the use of OAR vs EVAR by race/ethnicity classification. In total, primary payer and median income were also not statistically significant predictors of AAA treatment modality.

CONCLUSIONS

Our study found no statistical evidence of disparities with respect to race, insurance, or median income and use of OAR or EVAR for the management of rAAA.

Association between socioeconomic deprivation and presentation with a ruptured abdominal aortic aneurysm

OBJECTIVE

Given the ongoing nature of research in the social determinants space and urges to improve United States Preventive Services Task Force screening efforts for abdominal aortic aneurysms (AAAs), this project aims to characterize the association between the level of socioeconomic deprivation, rurality, and ruptured AAA (rAAA) presentation across the United States.

METHODS

We queried the Vascular Quality Initiative registry (2010-2019) for patients with AAAs. The area deprivation index (ADI) is an index from 1 to 100 used to capture socioeconomic status. ADI was grouped into quintiles, with the most deprived regions being quintile 5 and having the highest ADI index. Multivariable logistic regression assessed the association between ADI, rurality, and rAAA presentation overall and before age 65.

RESULTS

Of the 82,909 patients included, 11,458 patients (14%) resided in the most socioeconomically deprived regions, and 18,083 patients (22%) lived in rural regions. Overall, 6831 patients (8.2%) experienced an rAAA, with 4696 patients (69%) residing in the three most deprived quintiles. Most patients underwent endovascular repair (n = 67,933; 82%), followed by open repair (n = 14,976; 18%). On multivariable analysis, residence in the most socioeconomically deprived region was associated with a near 1.5-fold increased odds of presenting with an rAAA compared with a residence in the least deprived regions (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.31-1.63; P < .001), whereas urban residence was associated with a decreased odds to present with an rAAA compared with rural residence (OR, 0.84; 95% CI, 0.79-0.89; P < .001). When stratifying the study population by the United States Preventive Services Task Force recommended age for AAA screening (65 years old), 14,147 patients (17%) were under 65. Of those under 65, 1381 patients (9.8%) experienced a rAAA, and 9955 patients (71%) resided in the three most deprived quintiles. Residence in the most socioeconomically deprived region was associated with an increased odds of presenting with an rAAA compared with residence in the least deprived region (OR, 1.31; 95% CI, 1.01-1.69; P = .042). However, there were no significant associations between rural residence and increased rAAA presentation among individuals under 65 (OR, 1.07; 95% CI, 0.93-1.23; P = .36).

CONCLUSIONS

Among all patients in this study, patients residing in highly socioeconomically deprived or rural regions were more likely to present with an rAAA, but among those under 65, only residence in a socioeconomically deprived area was associated with increased odds of rAAA presentation. Understanding the effects of socioeconomic deprivation on rAAA presentation can identify at-risk populations for early AAA screening before rupture.

Disparities in unplanned surgery amongst medicare beneficiaries

BACKGROUND

While significant efforts have been made to understand surgical disparities for procedures that are performed in either the elective or unplanned settings, far less is known about procedures performed in both settings.

METHODS

Cross-sectional study of 1,135,743 Medicare beneficiaries undergoing incisional hernia repair, colectomy, or abdominal aortic aneurysm repair between 2014 and 2018. Risk-adjusted outcomes were assessed using multivariable logistic regression.

RESULTS

Compared to White beneficiaries, unplanned surgery rates were higher for Black (44.0%vs38.8%, OR = 1.29,p < 0.001) and Asian beneficiaries(40.4%vs38.8%,OR = 1.09,p < 0.001). While there were minimal differences in 30-day mortality for elective procedures, unplanned procedures demonstrated wider disparities (Black vs White 12.4%vs11.3%,OR = 1.11,p < 0.001; Asian vs White 13.2%vs11.3%,OR = 1.18,p < 0.001). Similar patterns were observed for readmissions.

CONCLUSIONS

Unplanned procedures are more common and demonstrate wider disparities in outcomes among minority Medicare beneficiaries. Reducing unplanned surgery rates among these groups may be an effective strategy to limit overall disparities in postoperative outcomes.

Racial disparities in presentation and outcomes for endovascular abdominal aortic aneurysm repair

OBJECTIVE

In the present study, we used a national database to identify racial differences in the presentation and outcomes for patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (EVAR) and identified areas for improving their care.

METHODS

We queried the EVAR-targeted National Surgical Quality Improvement Program database (2016-2019) to identify patients who had undergone EVAR for both ruptured and nonruptured AAAs. The patients were categorized according to race (White, Black, and Asian). Patients with a history of abdominal aortic surgery or an indication other than AAAs were excluded. The data was analyzed using the χ² and Kruskal-Wallis tests, presented as frequencies and percentages or median and interquartile range (IQR) for categorical and continuous variables, respectively.

RESULTS

We identified 3629 patients (16.6% female), including 3312 White (91.3%), 248 Black (6.8%), and 69 Asian (1.9%) patients. Black patients were more frequently women (27.0%) compared with White patients (15.9%) and were younger (median age, 71 years; IQR, 64-77 years) than White (median age, 73 years; IQR, 67-79 years) and Asian (median age, 76 years; IQR, 67-81 years) patients (P < .001 for both). The incidence of smoking, congestive heart failure, and dialysis dependency was highest for Black patients, and the incidence of obesity was lowest for Asian patients. The AAAs in Black patients extended more frequently beyond the aortic bifurcation (P = .047). In Asian patients, the internal iliac arteries were more involved (P = .040). For Black patients, 29.8% of the EVARs were performed in a nonelective setting compared with 20.2% for the White and 15.9% for the Asian patients (P < .001). The aneurysm diameter, nonruptured symptomatic rate, and rupture rate were similar across the groups (P = .807). The operative time was prolonged for Black (median, 128 minutes; IQR, 96-177 minutes) compared with White (median, 114 minutes; IQR, 84-162 minutes) patients (P < .001). Postoperatively, Black patients were more likely to require blood transfusion (16.5%) and had prolonged length of hospital stay (median, 2 days; IQR, 1-4 days) compared with White (10.0%; median, 1 day; IQR, 1-3 days) and Asian (4.3%; median, 1 day; IQR, 1-3 days) patients (P = .001 and P < .001, respectively). Black patients also had a higher 30-day readmission rate (P = .038). On multivariate analysis, Black race was an independent factor for length of stay >1 day after both elective and nonelective EVAR and 30-day readmission for elective EVAR, but not 30-day mortality after elective and nonelective EVAR.

CONCLUSIONS

In the present nationwide sample of EVAR cases, Black patients were more often women and younger. Despite similar rates of symptomatic and ruptured AAAs at presentation and 30-day mortality, Black patients more often presented and were treated during the same nonelective admission; they also had associated increased length of hospital stay and readmission. These findings signal a missed opportunity to diagnose, optimize, and treat this particular group of patients in an elective setting.

Disparities in reporting and representation by sex, race, and ethnicity in endovascular aortic device trials

OBJECTIVE

Vulnerable populations, including women and racial and ethnic minorities, have been historically underrepresented in clinical trials. We, therefore, studied the demographics of patients enrolled in pivotal endovascular aortic device trials in the United States.

METHODS

We queried the Food and Drug Administration (FDA) medical devices database for all FDA-approved endografts for the treatment of aortic aneurysms, transections, and dissections from September 1999 to November 2021. These included abdominal endovascular aortic repair (EVAR), thoracic EVAR (TEVAR), fenestrated EVAR (FEVAR) devices, and dissection stents. Multiple cases of approval for expanded indications were included separately. The primary outcomes included the proportion of trials reporting participant sex, race, and ethnicity and the proportion of enrolled participants across sex, racial, and ethnic groups.

RESULTS

The FDA provided 29 approvals from 29 trials of 24 devices: 15 EVAR devices (52%), 12 TEVAR devices (41%), 1 FEVAR device (3.4%), and 1 dissection stent (3.4%). These trials had included 4046 patients. Of the 29 trials, all had reported on the sex of the participants, and the median female enrollment was 21% (interquartile range [IQR], 11%-34%). The EVAR trials had the lowest female enrollment (11%; IQR, 8.7%-13%) compared with 41% (IQR, 27%-45%) in the TEVAR trials, 21% in the FEVAR trial, and 34% in the dissection stent trial (P < .01 for the difference). Only 52% of the trials had reported the three most common racial groups (White, Black, Asian), and only 48% had reported Hispanic ethnicity. The TEVAR trials were the most likely to report all three racial groups and Hispanic ethnicity (92% and 75%, respectively), while the EVAR trials had the lowest reporting rates (13% and 20%, respectively). Where reported, the median enrollment of racial and ethnic groups across the trials was as follows: Black patients, 9.8% (FEVAR, 0%; EVAR, 1.9%; TEVAR, 12%; dissection stent, 25%; P = .01); Asian patients, 2.4% (EVAR, 0.6%; FEVAR, 2.4%; TEVAR, 2.5%; dissection stent, 11%; P = .24); and Hispanic patients, 3.8% (EVAR, 1.3%; FEVAR, 2.4%; TEVAR, 3.9%; dissection stent, 4.1%; P = .75).

CONCLUSIONS

Racial and ethnic minority groups were underrepresented and underreported in pivotal aortic device trials that led to FDA approval. Female patients were also underrepresented in these aortic trials, especially for EVAR. These data suggest the need for standardization of reporting practices and minimum thresholds for minority and female participation in pivotal trials to promote equitable representation.

Disparities in 5-year outcomes and imaging surveillance following elective endovascular repair of abdominal aortic aneurysm by sex, race, and ethnicity

OBJECTIVES

Sex, racial, and ethnic disparities in postoperative outcomes following abdominal aortic aneurysm repair have been described, but differences in long-term outcomes are poorly understood. Our aim was to identify differences in 5-year outcomes and imaging surveillance after elective endovascular aortic aneurysm repair (EVAR) by sex, race, and ethnicity and to explore potential mechanisms underlying these differences.

METHODS

We identified patients undergoing elective EVAR in the Vascular Quality Initiative from 2003 to 2017 with linkage to Medicare claims through 2018 for long-term outcomes. Our primary outcome was 5-year aneurysm rupture. Secondary outcomes were 5-year reintervention and mortality and 2-year loss-to-imaging follow-up (defined as no aortic imaging from 6 to 24 months after EVAR). We used Kaplan-Meier and Cox regression analyses to evaluate these outcomes by sex/race/ethnicity and constructed multivariable models to explore potential contributing factors.

RESULTS

Among 16,040 patients, 11,764 (73%) were White males, 2891 (18%) were White females, 417 (2.6%) were Black males, 175 (1.1%) were Black females, 141 (0.9%) were Asian males, 34 (0.2%) were Asian females, 277 (1.7%) were Hispanic males, and 60 (0.4%) were Hispanic females. At 5 years, rupture rates were highest in Black females at 6.4% and lowest in white males at 2.3%. Compared with White males, rupture rates were higher in White females (hazard ratio [HR], 1.5; 95% confidence interval [CI], 1.1-2.0), Black females (HR, 2.5; 95% CI, 1.0-6.0), and Asian females (HR, 5.2; 95% CI, 1.3-21). White females also had higher mortality (HR, 1.2; 95% CI, 1.2-1.3) and loss-to-imaging-follow-up (HR, 1.2; 95% CI, 1.1-1.3), whereas Black females had higher mortality (HR, 1.4; 95% CI, 1.1-1.8) and reintervention (HR, 2.0; 95% CI, 1.4-2.8). Among other groups, Black males had higher reintervention (HR, 1.4; 95% CI, 1.0-1.8), and both Black and Hispanic males had higher loss-to-imaging-follow-up (Black: HR, 1.4; 95% CI, 1.1-1.7; Hispanic: HR, 1.3; 95% CI, 1.0-1.8). In adjusted analyses, White, Black, and Asian females remained at significantly higher risk for 5-year rupture after accounting for procedure year, clinical and anatomic characteristics, surgeon and hospital volume, and loss-to-imaging follow-up.

CONCLUSIONS

Compared with White male patients, Black females had higher 5-year aneurysm rupture, reintervention, and mortality after elective EVAR, whereas White females had higher rupture, mortality and loss-to-imaging-follow-up. Asian females also had higher rupture, and Black males had higher reintervention and loss-to-imaging-follow-up. These populations may benefit from improved preoperative counseling and clinical outreach after EVAR. A larger-scale investigation of current practice patterns and their impact on sex, racial, and ethnic disparities in late outcomes after EVAR is needed to identify tangible targets for improvement.

Epidemiology of age-, sex-, and race-specific hospitalizations for abdominal aortic aneurysms highlights gaps in current screening recommendations

BACKGROUND

The detection and elective repair of abdominal aortic aneurysms (AAA) guided by known risk-factor specific screening decrease AAA-related mortality. However, minimal epidemiologic data exist for AAA in female persons and racial minority groups. We established the contemporary risk of US AAA hospitalization across age, sex, and race.

METHODS

National Inpatient Sample and US Census (2012-2018) data were used to quantify age-, sex-, and race-specific incidences and adjusted odds ratios (aOR) of AAA hospitalizations (≥18 years), associated risk factors, and in-hospital mortality. Interaction terms evaluated subgroups.

RESULTS

Among 1,728,374,183 US residents during the study period (51.3% female; 78.4% White, 12.7% Black, 5.7% Asian), 211,501,703 were hospitalized (aged 57.56 ± 0.04 years; 58.4% female; 64.9% White, 14.3% Black, 2.5% Asian) of which 291,850 were for AAA (aged 73.17 ± 0.04 years; 22.6% female; 81.8% White, 5.6% Black, 1.6% Asian). An estimated 15.2 (95% CI, 15.1-15.3) and 1.7 (95% CI, 1.7-1.7) hospitalizations per 100,000 residents were for intact AAA (iAAA) and ruptured AAA (rAAA) AAA, respectively. In addition, 16.2% of iAAA (83.8% male; 79.1% White) and 18.4% of rAAA (86.4% male; 75.0% White) hospitalizations occurred in patients less than 65 years of age. For iAAA, female sex (aOR, 0.27; 95% CI, 0.27-0.28) compared with male sex and both Black (0.47; 95% CI, 0.45-0.49) and Asian (0.86; 95% CI, 0.83-0.93) persons compared with White persons had a reduced aOR for hospitalization. For rAAA, the reduced aOR persisted for female sex (0.33; 95% CI, 0.32-0.36) and for Black persons (0.52; 95% CI, 0.46-0.58). Although female sex demonstrated an overall decreased odds of AAA hospitalization, female persons who were older, Black, or had peripheral vascular disease (Pinteractions < .001) had a relative increase in AAA hospitalization aOR. Female sex (aOR, 1.54; 95% CI, 1.38-1.70), but not Black or Asian race, was associated with increased mortality which was more pronounced for iAAA (1.93; 95% CI, 1.66-2.25) than rAAA (1.29; 95% CI, 1.13-1.48]; Pinteraction < .001).

CONCLUSIONS

We confirmed a substantially decreased adjusted risk of AAA hospitalization for females and racial minority groups; however, aging and comorbid peripheral vascular disease decreased these differences. The disparate risk of AAA hospitalization by sex and race highlights the importance of inclusivity in future AAA studies.

Association between neighborhood deprivation and presenting with a ruptured abdominal aortic aneurysm before screening age

OBJECTIVE

Recent data indicate social determinants of health (SDOH) have a great impact on prevention and treatment outcomes across a broad variety of disease states, especially cardiovascular diseases. The area deprivation index (ADI) is a validated measure of neighborhood level disadvantage capturing key social determinate factors. Abdominal aortic aneurysm rupture (rAAA) is highly morbid, but also preventable through evidence-based screening. However, the association between rAAA and SDOH is poorly characterized. Our objective is to study the association of SDOH with rAAA and screening age.

METHODS

This retrospective study included patients who underwent operative repair of a rAAA at a multihospital healthcare system (2003-2019). Deprivation was measured by the ADI (scale 1-100), grouped into quintiles for simplicity, with higher quintiles indicating greater deprivation. Patients with the highest quintile ADI (89-100) were categorized as the most deprived. We investigated the association between neighborhood deprivation with the odds of (i) undergoing repair for rAAA before screening age 65 and (ii) undergoing endovascular aortic repair (EVAR) using logistic regression, sequentially modeling nonmodifiable then both nonmodifiable and modifiable confounding variables.

RESULTS

There were 632 patients who met the inclusion criteria (aged 74.2 ± 9.4 years; 174 women [27.6%]; 564 White [89.2%]; ADI 66.8 ± 22.3). Those from the most deprived neighborhoods (n = 118) were younger (71.7 ± 10.0 years vs 74.8 ± 9.2 years; P = .002), more likely to be female (36% vs 26%; P = .031), more likely to be Black (5.9% vs 0.4%; P = .007), and fewer underwent EVAR (28% vs 39.5%; P = .020) compared with those from other neighborhoods. On sequential modeling, residing in the most deprived neighborhoods was associated with undergoing rAAA repair before age 65 after adjusting for nonmodifiable factors (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.39-2.95; P < .001), and nonmodifiable as well as modifiable factors (OR, 2.22; 95% CI, 1.56-3.16; P < .001). Those in the most deprived neighborhoods had a lower odds of undergoing EVAR compared with open repair after adjusting for nonmodifiable factors (OR, 0.64; 95% CI, 0.41-0.98; P = .042), and nonmodifiable as well as modifiable factors (OR, 0.61; 95% CI, 0.37-0.99; P = .047).

CONCLUSIONS

Among patients who underwent rAAA, residing in the most deprived neighborhoods was associated with greater adjusted odds of presenting under age 65 and undergoing an open repair. These neighborhoods represent tangible geographic targets that may benefit from a younger screening age, enhanced education, and access to care. These findings stress the importance of developing strategies for early prevention and diagnosis of cardiovascular diseases among patients with disadvantageous SDOH.

Socioeconomic disparities in abdominal aortic aneurysm repair rates and survival

BACKGROUND

Abdominal aortic aneurysm (AAA) is more prevalent in socioeconomically disadvantaged areas. This study investigated socioeconomic disparities in AAA repair rates and survival.

METHODS

The study used ecological and cohort study designs, from 31 672 census areas in England (April 2006 to March 2018), the Index of Multiple Deprivation 2010 as the area-level deprivation indicator, and Poisson, logistic and Cox regression.

RESULTS

Some 77 606 patients (83.4 per cent men) in four age categories (55-64, 65-74, 75-84, 85 or more years) were admitted with AAA from a population aged at least 55 years of 14.7 million. Elective open and endovascular repair rates were 41 (95 per cent c.i. 23 to 61) and 60 (36 to 89) per cent higher respectively among men aged 55-64 years in the most versus least deprived areas by quintile. This differences diminished and appeared to reverse with increasing age, with 26 (-1 to 45) and 25 (13 to 35) per cent lower rates respectively in men aged 85 years or more in the most deprived areas. Men admitted from more deprived areas were more likely to die in hospital without aneurysm repair. Among those who had aneurysm repair, this was more likely to be for a ruptured aneurysm than among men from less deprived areas. For intact aneurysm repair, they were relatively more likely to have this during an emergency admission. The mortality rate after repair was higher for men from more deprived areas, although the hazard diminished with age. Patterns were unclear for women.

CONCLUSION

There were clear socioeconomic disparities in operation rates, mode of presentation, and outcome for AAA surgery. Policies are needed to address these disparities.

Racial Disparities Associated With Reinterventions After Elective Endovascular Aortic Aneurysm Repair

BACKGROUND

There are substantial racial and socioeconomic disparities underlying endovascular abdominal aortic aneurysm repair (EVAR) in the United States. To date, race-based variations in reinterventions following elective EVAR have not been studied. Here, we aim to examine racial disparities associated with reinterventions following elective EVAR in a real-world cohort.

MATERIALS AND METHODS

We used the Vascular Quality Initiative EVAR dataset to identify all patients undergoing elective EVAR between January 2009 and December 2018 in the United States. We compared the association of race with reinterventions after EVAR and all-cause mortality using Welch two-sample t-tests, multivariate logistic regression, and Cox proportional hazards analyses adjusting for baseline differences between groups.

RESULTS

At median follow-up of 1.1 ± 1.1 y (1.3 ± 1.4 y Black, 1.1 ± 1.1 y White; P = 0.02), a total of 1,164 of 42,481 patients (2.7%) underwent reintervention after elective EVAR, including 2.7% (n = 1,096) White versus 3.2% (n = 68) Black (P = 0.21). Black patients requiring reintervention were more frequently female, more frequently current or former smokers, and less frequently insured by Medicare/Medicaid (P < 0.05). After adjusting for baseline differences, the risk of reintervention after elective EVAR was significantly lower for Black versus White patients (HR 0.74, 95% CI 0.55-0.99; P = 0.04). All-cause mortality was comparable between groups (HR 0.81, 95% CI 0.33-2.00, P = 0.65).

CONCLUSIONS

There are significant differences between Black and White patients in the risk of reintervention after elective EVAR in the United States. The etiology of this difference deserves investigation.

Identifying patients at risk for nonroutine discharge after surgery for cervical myelopathy: an analysis from the Quality Outcomes Database

OBJECTIVE

Optimizing patient discharge after surgery has been shown to impact patient recovery and hospital/physician workflow and to reduce healthcare costs. In the current study, the authors sought to identify risk factors for nonroutine discharge after surgery for cervical myelopathy by using a national spine registry.

METHODS

The Quality Outcomes Database cervical module was queried for patients who had undergone surgery for cervical myelopathy between 2016 and 2018. Nonroutine discharge was defined as discharge to postacute care (rehabilitation), nonacute care, or another acute care hospital. A multivariable logistic regression predictive model was created using an array of demographic, clinical, operative, and patient-reported outcome characteristics.

RESULTS

Of the 1114 patients identified, 11.2% (n = 125) had a nonroutine discharge. On univariate analysis, patients with a nonroutine discharge were more likely to be older (age ≥ 65 years, 70.4% vs 35.8%, p < 0.001), African American (24.8% vs 13.9%, p = 0.007), and on Medicare (75.2% vs 35.1%, p < 0.001). Among the patients younger than 65 years of age, those who had a nonroutine discharge were more likely to be unemployed (70.3% vs 36.9%, p < 0.001). Overall, patients with a nonroutine discharge were more likely to present with a motor deficit (73.6% vs 58.7%, p = 0.001) and more likely to have nonindependent ambulation (50.4% vs 14.0%, p < 0.001) at presentation. On multivariable logistic regression, factors associated with higher odds of a nonroutine discharge included African American race (vs White, OR 2.76, 95% CI 1.38-5.51, p = 0.004), Medicare coverage (vs private insurance, OR 2.14, 95% CI 1.00-4.65, p = 0.04), nonindependent ambulation at presentation (OR 2.17, 95% CI 1.17-4.02, p = 0.01), baseline modified Japanese Orthopaedic Association severe myelopathy score (0-11 vs moderate 12-14, OR 2, 95% CI 1.07-3.73, p = 0.01), and posterior surgical approach (OR 11.6, 95% CI 2.12-48, p = 0.004). Factors associated with lower odds of a nonroutine discharge included fewer operated levels (1 vs 2-3 levels, OR 0.3, 95% CI 0.1-0.96, p = 0.009) and a higher quality of life at baseline (EQ-5D score, OR 0.43, 95% CI 0.25-0.73, p = 0.001). On predictor importance analysis, baseline quality of life (EQ-5D score) was identified as the most important predictor (Wald χ2 = 9.8, p = 0.001) of a nonroutine discharge; however, after grouping variables into distinct categories, socioeconomic and demographic characteristics (age, race, gender, insurance status, employment status) were identified as the most significant drivers of nonroutine discharge (28.4% of total predictor importance).

CONCLUSIONS

The study results indicate that socioeconomic and demographic characteristics including age, race, gender, insurance, and employment may be the most significant drivers of a nonroutine discharge after surgery for cervical myelopathy.

Epidemiology of abdominal aortic aneurysms

Abdominal aortic aneurysm (AAA) disease remains a major source of morbidity in developed countries and can progress to life-threatening rupture if left untreated, with exceedingly high mortality. The goal of AAA management is to identify and electively repair AAAs before rupture. AAA disease burden and outcomes have improved over time with declining tobacco use and advancements in care across patients' disease course. The introduction of endovascular AAA repair, in particular, has allowed for elective AAA repair in patients previously considered too high risk for open surgery and has contributed to lower rates of AAA rupture over time. However, these improved outcomes are not universally experienced, and disparities continue to exist in the detection, treatment, and outcomes of AAA by sex, race, and ethnicity. Mitigating these disparities requires enhanced, focused efforts at preventing disease, promoting health, and delivering appropriate care among an increasingly diverse patient population.

Disparity in clinical outcomes after cardiac surgery between private and public (NHS) payers in England

BACKGROUND

There is little known about how payer status impacts clinical outcomes in a universal single-payer system such as the UK National Health Service (NHS). The aim of this study was to evaluate the relationship between payer status (private or public) and clinical outcomes following cardiac surgery from NHS providers in England.

METHODS

The National Adult Cardiac Surgery Audit (NACSA) registry was interrogated for patients who underwent adult cardiac surgery in England from 2009 to 2018. Information on socioeconomic status were provided by linkage with the Iteration of the English Indices of Deprivation (IoD). The primary outcome was in-hospital mortality. Secondary outcomes included incidence of in-hospital postoperative cerebrovascular accident (CVA), renal dialysis, sternal wound infection, and re-exploration. To assess whether payer status was an independent predictor of in-hospital mortality, binomial generalized linear mixed models (GLMM) were fitted along with 17 items forming the EuroSCORE and the IoD domains.

FINDINGS

The final sample consisted of 280,209 patients who underwent surgery in 31 NHS hospitals in England from 2009 to 2018. Of them, 5,967 (2.1%) and 274,242 (97.9%) were private and NHS payers respectively. Private payer status was associated with a lower risk of in-hospital mortality (OR 0.79; 95%CI 0.65 - 0.97;P = 0.026), CVA (OR 0.77; 95%CI 0.60 - 0.99; P = 0.039), need for re-exploration (OR 0.84; 95%CI 0.72 - 0.97; P = 0.017) and with non-significant lower risk of dialysis (OR 0.84; 95%CI 0.69 - 1.02; P = 0.074). Private payer status was found to be independently associated with lower risk of in-hospital mortality in the elective subgroup (OR 0.76; 95%CI 0.61 - 0.96; P = 0.020) but not in the non-elective subgroup (OR 1.01; 95%CI 0.64 - 1.58; P = 0.976).

INTERPRETATION

In conclusion, using a national database, we have found evidence of significant beneficial effect of payer status on hospital outcomes following cardiac surgery in favour of private payers regardless their socioeconomic factors.

Treatment Utilization and Socioeconomic Disparities in the Surgical Management of Gastroparesis

BACKGROUND

Gastroparesis is an end-organ sequela of diabetes. We evaluated the roles of race and socioeconomic status in hospitalization rates and utilization of surgical treatments in these patients.

METHODS

Data was extracted from the National Inpatient Sample (NIS) between the years 2012 and 2014, and any discharge diagnosis of gastroparesis (536.3) was included. Gastrostomy, jejunostomy, and total parenteral nutrition were considered nutritional support procedures, and procedures aimed at improving motility were considered definitive disease-specific procedures: pyloroplasty, endoscopic pyloric dilation, gastric pacemaker placement, and gastrectomy.

RESULTS

There were 747,500 hospitalizations reporting a discharge diagnosis of gastroparesis. On multivariable analysis, black race (OR 1.93, 95% CI 1.89-1.98; p < 0.001) and Medicaid insurance (OR 1.46, 95% CI 1.42-1.50; p < 0.001) were the strongest socioeconomic risk factors for hospitalization due to gastroparesis. Patients in urban teaching institutions were most likely to undergo a surgical intervention for gastroparesis (5.53% of patients versus 3.94% of patients treated in urban non-teaching hospitals and 2.38% of patients in rural hospitals; p < 0.001). Uninsured patients were less than half as likely to receive treatment compared to those with private insurance (OR 0.41, 95% CI 0.34-0.48; p < 0.001), and black patients had an OR 0.75 (95% CI 0.69-0.81; p < 0.001) for receiving treatment. Urban teaching hospitals had a twofold higher likelihood of intervention (OR 2.12, 95% CI 1.84-2.44; p < 0.001).

CONCLUSIONS

Marked racial and economic disparities exist in surgical distribution of care for gastroparesis, potentially driven by differences in utilization of care.

A National Analysis of Traumatic Thoracic Aortic Repair: Does Insurance Status Matter?

BACKGROUND

Traumatic thoracic aortic injuries (TAIs) carry a substantial mortality. Our study aim was to evaluate the impact of insurance status on outcomes in severely injured trauma patients after either thoracic endovascular aortic repair (TEVAR) or open repair using the National Trauma Data Bank Research Data Set (NTDB-RDS).

METHODS

The NTDB-RDS was reviewed for outcomes in severely injured patients and TAI repair method (TEVAR vs open). Patients were divided into insured (Medicaid, Medicare, private insurance) and uninsured (self-pay) status groups. Patients were further divided by injury severity score (ISS) of 15-24 and ≥25 to adjust for injury burden. Demographic characteristics and outcome measures were compared. Chi-square, t-test, and analysis of variance were used with significance defined as P < .05.

RESULTS

Within the NTDB-RDS, a review of nearly 1 million patients led to 241 that underwent repair for TAI and had insurance status and repair type documented. 88.8% (214/241) of patients were insured, while 11.2% (27/241) of patients were uninsured. There were no significant differences in repair type based on insurance status. For open repair with an ISS ≥25, mortality was significantly higher in the uninsured group compared with insured (55.5% vs 21.9%, P = .001).

CONCLUSION

For open repair in patients with TAI and high injury burden, uninsured status was associated with a significant increase in mortality rate compared with insured patients. Future studies should investigate the effect of insurance type on TAI outcomes and causes of higher mortality in uninsured patients.

Disparities in mortality after abdominal aortic aneurysm repair are linked to insurance status

OBJECTIVE

The objective of this study was to determine differences in mortality after abdominal aortic aneurysm (AAA) repair based on insurance type.

METHODS

In this retrospective cohort study, data from all-payer patients in nonpsychiatric hospitals in New York, Maryland, Florida, Kentucky, and California from January 2007 to December 2014 (excluding California, ending December 2011) were extracted from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. There were 90,102 patients ≥18 years old with available insurance data who underwent open AAA repair or endovascular aneurysm repair (EVAR) identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes 3844, 3925, and 3971. EVAR patients were identified using the procedure code 3971, and the remainder of cases were categorized as open. Patients were divided into cohorts by insurance type as Medicare, Medicaid, uninsured (self-pay/no charge), other, or private insurance. Patients were further stratified for subgroup analyses by procedure type. Unadjusted rates of in-hospital mortality, the primary outcome, as well as secondary outcomes, such as surgical urgency, 30-day and 90-day readmissions, length of stay, total charges, and postoperative complications, were examined by insurance type. Adjusted odds ratios (ORs) for in-hospital mortality were calculated using multivariate logistic regression models fitted to the data. The multivariate models included patient-, surgical-, and hospital-specific factors with bivariate baseline testing suggestive of association with insurance status in addition to variables that were selected a priori.

RESULTS

Medicaid and uninsured patients had the highest rates of mortality relative to private insurance beneficiaries in all cohorts. Medicaid patients incurred a 47% increase in the odds of mortality, the highest among the insured, after all AAA repairs (OR, 1.47; 95% confidence interval [CI], 1.23-1.76), whereas uninsured patients experienced a 102% increase in the odds of mortality (OR, 2.02; 95% CI, 1.54-2.67). Subgroup analyses for open AAA repair and EVAR corroborated that Medicaid insurance (open repair OR, 1.37 [95% CI, 1.14-1.64]; EVAR OR, 2.06 [95% CI, 1.40-3.04]) and uninsured status (open repair OR, 1.85 [95% CI, 1.35-2.54]; EVAR OR, 2.96 [95% CI, 1.82-4.81]) were associated with the highest odds of mortality after both procedures separately.

CONCLUSIONS

This study demonstrates that Medicaid insurance and uninsured status are associated with higher unadjusted rates and adjusted ORs for in-hospital mortality after AAA repair relative to private insurance status. Primary payer status therefore serves as an independent predictor of the risk of death subsequent to AAA surgical interventions.

Patient Race and Insurance Status Do Not Impact the Treatment of Simple Mandibular Fractures

INTRODUCTION

Health-care disparities have been reported throughout medical literature for decades. While blatant explicit bias is not prevalent, a substantial body of research has been published suggesting that systemic biases related to sex, race, income, and insurance status likely exist. To our knowledge, no study has assessed the impact of patient race and insurance status on clinical decision-making in facial fracture repair in the United States. Thus, the objective of this project was to assess if race and insurance status impacted whether patients obtained open or closed treatment of simple mandibular fractures.

METHODS

Patients who had either open or closed treatment of mandibular fractures were extracted from the 2012 and 2013 National Inpatient Sample and analyzed. Patients who had a length of stay longer than 3 days or died during their inpatient stay were excluded. These exclusion criteria were used to control for patients with polytrauma as well as complicated fractures. Univariate analysis was undertaken to elucidate different variable associations with the type of reduction performed. All covariates were then entered into a multivariable logistic regression model to test the variables simultaneously.

RESULTS

Patients with simple condylar, alveolar border, and closed mandibular fractures were more likely to undergo closed reduction (CR) on univariate analysis, as were patients with female gender and a fall mechanism (P value < .05). African Americans, Hispanics, and patients without insurance were more likely to undergo open reduction on univariate analysis (P value < .05). Multivariate analysis demonstrated that patients with simple condylar, subcondylar, alveolar border, or closed mandibular fractures were more likely to undergo a CR, as were patients with female gender and a firearm or fall mechanism (P < .05). However, neither race nor insurance status demonstrated a statistically significant association with closed or open reduction.

CONCLUSION

Anatomic location and mechanism of injury were the variables found to be significantly associated with patients undergoing open reduction versus CR of simple mandibular fractures-not race or insurance status.

Association of Sex With Repair Type and Long-term Mortality in Adults With Abdominal Aortic Aneurysm

IMPORTANCE

Sex-based differences exist in the prevalence and clinical presentation of abdominal aortic aneurysm (AAA). However, it is unclear if sex is associated with AAA repair type and long-term mortality.

OBJECTIVE

To investigate whether a sex-related difference exists in mortality risk after AAA repair owing to differences in repair type.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study uses data from the Vascular Quality Initiative, a national clinical registry, and Medicare claims to investigate endovascular and surgical repair procedures performed between January 1, 2003, and September 30, 2015, in patients aged 65 years or older with AAA. The data were analyzed from October 1, 2018, to November 19, 2019.

EXPOSURE

Sex of the patient.

MAIN OUTCOMES AND MEASURES

Endovascular (EVR) or open surgical AAA repair type and subsequent long-term, all-cause mortality.

RESULTS

In this cohort study of 16 386 patients, 12 757 (77.9%) were men and 3629 (22.1%) were women. Women were more likely than men to be older (mean [SD] age, 77 [6.5] years vs 75 [6.6] years; P < .001), active smokers (33% vs 28%; P < .001), and to have smaller aneurysms (mean [SD] diameter, 57 [11.7] mm vs 59 [17.7] mm; P < .001). Surgical AAA repair was performed in 27% (983 of 3629) of women compared with 18% (2328 of 12 757) of men (P < .001). After inverse probability weighting for risk adjustment, women were more likely to receive open surgical repair than EVR repair (risk ratio, 1.65; 95% CI, 1.51-1.80). The 10-year unadjusted survival rate after EVR repair was 14% lower in women than in men (23% vs 37%; log-rank P < .001), but the rates were comparable after open surgical repair (36% in men vs 32% in women; log-rank P = .22). Risk-adjusted analysis showed that women were associated with higher mortality rates after EVR repair (hazard ratio, 1.13; 95% CI, 1.03-1.24), whereas both men and women had a similar risk of death after open surgical repair (hazard ratio, 0.94; 95% CI, 0.84-1.06). After further stratification by symptom severity, higher risk of mortality among women was limited to elective EVR and open surgical repair for ruptured AAA.

CONCLUSIONS AND RELEVANCE

In this study, women were 65% more likely than men to undergo open surgical repair. After EVR repair, women were 13% more likely to die than men, although no sex-based difference in mortality was found after open surgical repair. The differential treatment benefit of EVR repair in women is concerning given the shift toward an EVR-first approach to AAA repair.

The Impact of the Affordable Care Act Medicaid Expansion on Vascular Surgery

BACKGROUND

The Affordable Care Act (ACA) Medicaid expansion increased Medicaid eligibility such that all adults with an income level up to 138% of the federal poverty threshold in 2014 qualified for Medicaid benefits. Prior studies have shown that the ACA Medicaid expansion was associated with increased access to care. The impact of the ACA Medicaid expansion on patients undergoing complex care for major vascular pathology has not been evaluated.

METHODS

The Healthcare Cost and Utilization Project State Inpatient Database was used to identify patients undergoing care for major vascular pathology in 6 states from 2010 to 2014. The analysis cohort included adult patients between the ages of 18 and 64 years who underwent a nonemergent surgical procedure for an abdominal aortic aneurysm, thoracic aortic aneurysm, carotid artery stenosis, peripheral vascular disease, or chronic kidney disease. Poisson regression was used to determine the incidence rate ratios (IRRs).

RESULTS

There were a total of 83,960 patients in the study cohort. Compared with nonexpansion states, inpatient admissions for Medicaid patients with an abdominal or thoracic aneurysm and carotid stenosis diagnosis increased significantly (IRR, 1.20, 1.27, 1.06, respectively; P < 0.05) in states that expanded Medicaid. Vascular-related surgeries increased for carotid endarterectomy, lower extremity revascularization, lower extremity amputation, and arteriovenous fistula in expansion states (IRR, 1.24, 1.10, 1.11, 1.16, respectively; P < 0.05) compared with nonexpansion states.

CONCLUSIONS

In states that expanded Medicaid coverage under the ACA, the rate of vascular-related surgeries and admissions for Medicaid patients increased. We conclude that expanding insurance coverage results in enhanced access to vascular surgery.

Impact of primary payer status on outcomes among patients with burn injury: A nationwide analysis

OBJECTIVE

To study the relationship between insurance provider and important outcomes among patients with burn injury.

METHODS

Adults with burn injury were selected from the National Inpatient Sample. The primary outcome was inpatient mortality. Secondary outcomes were morbidity (septic shock and prolonged mechanical ventilation (PMV)), treatment metrics (time to surgery and parenteral or enteral nutrition (P/E-nutrition)) and resource utilization (length of stay (LOS) and total hospitalization costs and charges). Confounders were adjusted for using multivariate regression analysis.

RESULTS

Insurance did not affect in-hospital mortality rate. Compared with private insurance, Medicaid was associated with higher septic shock rate (aOR: 2.14 (1.04-4.39), longer LOS (adjusted mean difference (aMD): 2.79 (0.50-5.08) days) and higher costs (aMD: $16,161 ($4789-$27,534) while uninsured patients has shorter LOS (aMD: -2.57 (-4.59--0.55) days), lower charges (aMD: $-37,792 $(-65,550-$-10,034) and costs (aMD: $-8563 ($15,581-$-1544)). Insurance did not affect PMV rates or time to surgery or P/E-nutrition.

CONCLUSIONS

Primary payer does not affect in-hospital mortality or treatment metrics among patients admitted for burn injury. However, compared with private insurance, Medicaid was associated with both higher morbidity and resource utilization, whereas uninsured patients had lower resource utilization.

Understanding abdominal aortic aneurysm epidemiology: socioeconomic position affects outcome

Background

Low socioeconomic position (SEP) has been demonstrated to negatively influence outcome in several cardiovascular patient groups. The aim of this study was to analyse time trends of incidence of intact abdominal aortic aneurysm (iAAA) and ruptured AAA (rAAA), respectively, and to investigate whether SEP had any influence on the probability to present with rupture and, finally, to determine the impact of SEP on outcome.

Methods

Nationwide population-based study including all individuals with iAAA or rAAA in Sweden during 2001–2015.

Results

The number of individuals with an AAA was 41 222; the majority were identified as iAAA 33 254 (80.7%) and 7968 (19.3%) as rAAA. Time trends showed decreasing incidence of rAAA but increase in iAAA during the study period. Individuals with low income or low educational level were more likely to present with a rAAA rather than iAAA: OR 2.16 (95 % CI 1.98 to 2.36, p<0.001) and OR 1.33 (95 % CI 1.21 to 1.46, p<0.001), respectively. Low income was also associated with increased 90-day mortality and 1-year mortality after treatment for rAAA, OR 1.42 (95% CI 1.07 to 1.89, p=0.014) and OR 1.39 (95% CI 1.13 to 1.97, p=0.005).

Conclusion

This large nationwide study showed a decreasing incidence of rAAA. Individuals with low SEP were found to have an augmented risk of presenting with rAAA rather than iAAA and, in addition, to fare worse after repair. Consequently, SEP should be regarded as a relevant risk factor that should be included in considerations for improved care flow of patients with AAA.

Racial disparities in surgical outcomes of patients with Inflammatory Bowel Disease

BACKGROUND

Inflammatory Bowel Disease (IBD) has not historically been a focus of racial health disparities research. IBD has been increasing in the black community. We hypothesized that outcomes following surgery would be worse for black patients.

METHODS

A retrospective cohort study of death and serious morbidity (DSM) of patients undergoing surgery for IBD was performed using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP 2011-2014). Multivariable logistic regression modeling was performed to evaluate associations between race and outcomes.

RESULTS

Among 14,679 IBD patients, the overall rate of DSM was 20.3% (white: 19.3%, black 27.0%, other 23.8%, p < 0.001). After adjustment, black patients remained at increased risk of DSM compared white patients (OR: 1.37; 95% CI 1.14-1.64).

CONCLUSIONS

Black patients are at increased risk of post-operative DSM following surgery for IBD. The elevated rates of DSM are not explained by traditional risk factors like obesity, ASA class, emergent surgery, or stoma creation.

Racial and Socioeconomic Disparities After Carotid Procedures

Background:

Race has been associated with inferior outcomes after multiple procedures, but the association of socioeconomic status with procedures for cerebrovascular disease is not well established.

Materials and Methods:

Elective carotid artery stenting (CAS) and carotid endarterectomy (CEA) procedures were identified in the National Inpatient Sample, 2012 to 2014. Median household income was estimated from patient ZIP codes. Chi-square and multivariable logistic regression analysis evaluated outcomes, accounting for age, race, gender, comorbidities, procedure, income, insurance, and hospital characteristics.

Results:

We identified 234 825 carotid procedures (205 835 CEA and 28 990 CAS). Blacks and Hispanics were more likely to be among the lowest quartile income patients (LQIPs) compared to whites (53.5% and 38.7% vs 27.0%, respectively; P < .0002). Compared to highest income quartile patients, LQIP had lower rates of private insurance (16.3% vs 22.0%) and higher Medicaid use (4.7% vs 2.0%; all P < .0002). Lowest quartile income patients were more likely to receive CAS (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 1.27-1.37), as were blacks and Hispanics (OR = 1.09, 95% CI: 1.02-1.26; OR = 1.31, 95% CI: 1.24-1.40, respectively). In multivariable regression, postoperative stroke was associated with LQIP, black race, and Hispanic ethnicity (OR = 1.16, 95% CI: 1.06-1.28; OR = 1.52, 95% CI: 1.33-1.73; OR = 1.43, 95% CI: 1.24-1.64, respectively). Subgroup analysis demonstrated that whites also had higher odds of stroke in the lower income quartile (OR = 1.2, 95% CI: 1.1-1.4). Mortality was associated with LQIP (OR = 1.6, 95% CI: 1.2-2.1), black race (OR = 1.8, 95% CI: 1.4-2.5), and CAS (OR = 1.3, 95% CI: 1.1-1.6). Length of stay in the lowest income quartile was longer than in patients with the highest income ( P < .0001).

Conclusions:

Race was associated with increased hospital mortality, postoperative stroke, and overall complications after carotid procedures. Lower income was significantly associated with increased stroke and mortality irrespective of race. Disparate utilization and outcomes for carotid procedures are multifactorial. Efforts to reduce disparities will need to focus on race and other socioeconomic factors.

Socioeconomic factors and mortality in emergency general surgery: trends over a 20-year period

BACKGROUND

Socioeconomic factors such as race, insurance, and income quartiles have been identified as independent risk factors in emergency general surgery (EGS), but this impact has not been studied over time. We sought to identify trends in disparities in EGS-related operative mortality over a 20-y period.

METHODS

The National Inpatient Sample was used to identify patient encounters coded for EGS in 1993, 2003, and 2013. Logistic regression models were used to examine the adjusted relationship between race, primary payer status, and median income quartiles and in-hospital mortality after adjusting for patients' age, gender, Elixhauser comorbidity score, and hospital region, size, and location-cum-teaching status.

RESULTS

We identified 391,040 patient encounters. In 1993, Black race was associated with higher odds of in-hospital mortality (odds ratio [95% confidence interval]: 1.35 [1.20-1.53]) than White race, although this difference dissipated in subsequent years. Medicare, Medicaid, and underinsured patients had a higher odds of mortality than those with private insurance for the entire 20-y period; only the disparity in the underinsured decreased over time (1993, 1.63 [1.35-1.98]; 2013, 1.41 [1.20-1.67]). In 2003 (1.23 [1.10-1.38]) and 2013 (1.23 [1.11-1.37]), patients from the lowest income quartile were more likely to die after EGS than patients from the highest income quartile.

CONCLUSIONS

Socioeconomic disparities in EGS-related operative morality followed inconsistent trends. Over time, while gaps in in-hospital mortality among Blacks and Whites have narrowed, disparities among patients belonging to lowest income quartile have worsened. Medicare and Medicaid beneficiaries continued to experience higher odds of in-hospital mortality relative to those with private insurance.

Effectiveness of open versus endovascular abdominal aortic aneurysm repair in population settings: A systematic review of statewide databases

BACKGROUND

Patient outcomes after open abdominal aortic aneurysm and endovascular aortic aneurysm repair have been widely reported from several large, randomized, controlled trials. It is not clear whether these trial outcomes are representative of abdominal aortic aneurysm repair procedures performed in real-world hospital settings across the United States. This study was designed to evaluate population-based outcomes after endovascular aortic aneurysm repair versus open abdominal aortic aneurysm repair using statewide inpatient databases and examine how they have helped improve our understanding of abdominal aortic aneurysm repair.

METHODS

A systematic search of MEDLINE, EMBASE, and CINAHL databases was performed to identify articles comparing endovascular aortic aneurysm repair and open abdominal aortic aneurysm repair using data from statewide inpatient databases. This search was limited to studies published in the English language after 1990, and abstracts were screened and abstracted by 2 authors.

RESULTS

Our search yielded 17 studies published between 2004 and 2016 that used data from 29 different statewide inpatient databases to compare endovascular aortic aneurysm repair versus open abdominal aortic aneurysm repair. These studies support the randomized, controlled trial results, including a lower mortality associated with endovascular aortic aneurysm repair extended from the perioperative period up to 3 years after operation, as well as a higher complication rate after endovascular aortic aneurysm repair. The evidence from statewide inpatient database analyses has also elucidated trends in procedure volume, patient case mix, volume-outcome relationships, and health care disparities associated with endovascular aortic aneurysm repair versus open abdominal aortic aneurysm repair.

CONCLUSION

Population analyses of endovascular aortic aneurysm repair and open abdominal aortic aneurysm repair using statewide inpatient databases have confirmed short- and long-term mortality outcomes obtained from large, randomized, controlled trials. Moreover, these analyses have allowed us to assess the effect of endovascular aortic aneurysm repair adoption on population outcomes and patient case mix over time.

Variations in postoperative complications according to race, ethnicity, and sex in older adults

OBJECTIVES

To explore differences in the incidence of postoperative complications between three racial and ethnic groups (white, black, Hispanic) before and after taking into account potentially confounding patient and hospital characteristics.

DESIGN

Cross-sectional study using 2006 to 2007 administrative discharge data from hospitals in four states (CA, PA, NJ, FL) linked to American Hospital Association Annual Survey data and data from the U.S. Census. Risk-adjusted logistic regression models were used in the analyses.

SETTING

Six hundred U.S. adult nonfederal acute care hospitals.

PARTICIPANTS

Individuals aged 65 and older undergoing general, orthopedic, or vascular surgery (N = 587,314; 86% white, 6% black, 8% Hispanic).

MEASUREMENTS

Thirteen frequent postoperative complications.

RESULTS

When considered without controls, black patients had significantly greater odds than white patients of developing 12 of the 13 complications, by factors (ORs) ranging from 1.09 to 2.69. Hispanic patients had significantly greater odds than white patients in nine of the 13 complications (ORs = 1.11-1.82) and significantly lower odds than white patients on two of the other four (ORs both = 0.84). The fully adjusted models that accounted for hospital and especially patient characteristics substantially diminished the number of complications for which black and Hispanic patients had significantly greater odds than white patients. Many of the significant differences between black, Hispanic, and white patients that persisted after controls were different for men and women.

CONCLUSION

Older black and Hispanic individuals have greater odds than white individuals of developing a vast majority of postoperative complications. Procedure type and health status largely explained differences in postoperative complication risk, which are frequently conditional on sex.

Effect of insurance status on patients admitted for acute diverticulitis

AIM

The study aimed to evaluate the relationship between insurance status and the management and outcome of acute diverticulitis in a nationally representative sample.

METHOD

A retrospective cohort analysis of a nationally representative sample of 1 031 665 hospital discharges of patients admitted for acute diverticulitis in the 2006-2009 Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project data set. The main outcome measures included state at presentation (complicated/uncomplicated), management (medical/surgical), time to surgical intervention, type of operation and inpatient death.

RESULTS

In total, 207 838 discharges were identified (including 37.0% with private insurance, 49.3% in Medicare, 5.6% in Medicaid and 5.8% uninsured) representing 1 031 665 total discharges nationally. Medicare patients were more likely to present with complicated diverticulitis compared with private insurance patients (23.8% vs 15.1%). Time to surgical intervention differed by insurance status. After adjusting for patient, hospital and treatment factors, Medicare patients were less likely than those with private insurance to undergo a procedure (Medicare OR = 0.86, 95% CI: 0.82-0.91), while the uninsured were more likely to undergo drainage (OR = 1.30, 95% CI: 1.16-1.46) or a colostomy only (OR = 1.70, 95% CI: 1.24-2.33). All patients without private insurance were more likely to die in hospital (Medicare OR = 1.29, 95% CI: 1.09-1.52; Medicaid OR = 1.55, 95% CI: 1.22-1.97; uninsured OR = 1.41, 95% CI: 1.07-1.87).

CONCLUSION

In a nationally representative sample of patients with acute diverticulitis, patient management and outcome varied significantly by insurance status, despite adjustment for potential confounders. Providers might need to heighten surveillance for complications when treating patients without private insurance to improve outcome.

Primary payer status is associated with mortality and resource utilization for coronary artery bypass grafting

BACKGROUND

Medicaid and uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes after coronary artery bypass grafting (CABG) in the United States is dependent on primary payer status.

METHODS AND RESULTS

From 2003 to 2007, 1,250,619 isolated CABG operations were evaluated using the Nationwide Inpatient Sample (NIS) database. Patients were stratified by primary payer status: Medicare, Medicaid, uninsured, and private insurance. Hierarchical multiple regression models were applied to assess the effect of primary payer status on postoperative outcomes. Unadjusted mortality for Medicare (3.3%), Medicaid (2.4%), and uninsured (1.9%) patients were higher compared with private insurance patients (1.1%, P<0.001). Unadjusted length of stay was longest for Medicaid patients (10.9 ± 0.04 days) and shortest for private insurance patients (8.0 ± 0.01 days, P<0.001). Medicaid patients accrued the highest unadjusted total costs ($113 380 ± 386, P<0.001). Importantly, after controlling for patient risk factors, income, hospital features, and operative volume, Medicaid (odds ratio, 1.82; P<0.001) and uninsured (odds ratio, 1.62; P<0.001) payer status independently conferred the highest adjusted odds of in-hospital mortality. In addition, Medicaid payer status was associated with the longest adjusted length of stay and highest adjusted total costs (P<0.001).

CONCLUSIONS

Medicaid and uninsured payer status confers increased risk adjusted in-hospital mortality for patients undergoing coronary artery bypass grafting operations. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors. Possible explanations include delays in access to care or disparate differences in health maintenance.

Standardization of outcome measures in clinical trials of pharmacological treatment for abdominal aortic aneurysm

An abdominal aortic aneurysm (AAA) is a common aortic wall disease with an increased prevalence in the elderly population (4-8% for those aged >65 years). Many AAAs are slow growing and remain insidious. Current standard of care for patients with small AAAs (<49 mm) is surveillance, with interventional therapy (open surgical repair or endovascular aneurysm repair) recommended for large (>50-55 mm), rapidly growing (>10 mm/year) or symptomatic AAAs. Although open surgical repair or endovascular aneurysm repair are effective, significant short- and long-term postoperative morbidity and mortality occurs. Currently, there is no pharmacological treatment specific for AAA; the need for the development of targeted pharmacological therapies based on clinically relevant and feasible outcomes acceptable to the medical community, regulatory agencies and third-party payers is high. A consensus on such end points will be critical to accelerating the development of pharmacological agents to prevent formation, arrest the expansion and reduce the rupture risk of AAA.

The Impact of Hospital Volume on the Development of Infectious Complications After Elective Abdominal Aortic Surgery in the Medicare Population

Objective: A relationship exists between higher hospital volume and lower mortality, yet the impact of hospital volume on infectious complications after elective abdominal aortic aneurysm (AAA) repair is unknown. Methods: The Medicare database (2005-2007) was utilized. Top 10% for volume were categorized as high-volume (HV) and compared to low-volume (LV) centers for infectious complications and utilization. Results: A total of 42 155 endovascular aneurysm repair (EVAR) and 17 210 open AAA were identified. Mortality in HV was significantly lower than in LV after EVAR and open AAA. After EVAR, HV had lower than LV rates of overall infection (3.10% vs 3.51%; P = .021), PNA (0.94% vs 1.27%, P = .002), and sepsis (0.31% vs 0.45%; P = .03). Length of stay (LOS) and total hospital charges were significantly lower at HV compared to LV after both EVAR and open AAA. Conclusion: For Medicare beneficiaries, undergoing elective AAA repair at hospitals performing higher volume significantly reduced postoperative infectious complications and hospital resource utilization. Further analysis identifying systematic reasons for disparities may offer cost savings and improve outcomes.

Primary payer status affects outcomes for cardiac valve operations

BACKGROUND

Disparities in health care have been reported among various patient populations, and the uninsured and Medicaid populations are a major focus of current health care reform. The objective of this study was to examine the influence of primary payer status on outcomes after cardiac valve operations in the United States.

METHODS

From 2003 to 2007, 477,932 patients undergoing cardiac valve operations were evaluated using discharge data from the Nationwide Inpatient Sample database. Records were stratified by primary payer status: Medicare (n = 57,249, age = 74.0 ± 0.02 years), Medicaid (n = 5,868, age = 41.2 ± 0.13 years), uninsured (n = 2,349, age = 49.7 ± 0.15 years), and private insurance (n = 31,808, age = 53.3 ± 0.04 years). Multivariate regression models were applied to assess the independent effect of payer status on in-hospital outcomes.

RESULTS

Preoperative patient risk factors were more common among Medicare and Medicaid populations. Unadjusted mortality and complication rates for Medicare (6.9%, 36.6%), Medicaid (5.7%, 31.4%) and uninsured (5.2%, 31.4%) patient groups were higher compared with private insurance groups (2.9%, 29.9%; p < 0.001). In addition, mortality was lowest for patients with private insurance for all types of valve operations. Medicaid patients accrued the longest unadjusted hospital length of stay and highest total hospital costs compared with other payer groups (p < 0.001). Importantly, after risk adjustment, uninsured and Medicaid payer status conferred the highest odds of risk-adjusted mortality and morbidity compared with private insurance status, which were higher than those for Medicare.

CONCLUSIONS

Uninsured and Medicaid payer status is associated with increased risk-adjusted in-hospital mortality and morbidity among patients undergoing cardiac valve operations compared with Medicare and private insurance. In addition, Medicaid patients accrued the longest hospital stays and highest total costs. Primary payer status should be considered as an independent risk factor during preoperative risk stratification and planning.

Abdominal aortic diameter and vascular atherosclerosis: the Multi-Ethnic Study of Atherosclerosis

OBJECTIVES

To gain insight into early mechanisms of aortic widening, we examined associations between the diameter of the abdominal aorta (AD) and cardiovascular disease (CVD) risk factors and biomarkers, as well as measures of subclinical atherosclerosis, in a multi-ethnic population.

DESIGN

Cross-sectional cohort.

METHODS

A total of 1926 participants (mean age 62, 50% women) underwent chest and abdomen scanning by computed tomography, ultrasound of the carotid arteries, and CVD risk factor assessment. AD was measured 5 cm above and at the bifurcation.

RESULTS

In a model containing traditional CVD risk factors, biomarkers and ethnicity, only age (standardized β = 0.97), male sex (β = 1.88), body surface area (standardized β = 0.92), current smoking (β = 0.42), D-dimer levels (β = 0.19) and hypertension (β = 0.53) were independently and significantly associated with increasing AD (in mm) at the bifurcation; use of cholesterol-lowering medications predicted smaller AD (β = -0.70) (P < 0.01 for all). These findings were similar for AD 5 cm above the bifurcation with one exception: compared to Caucasian-Americans, Americans of Chinese, African and Hispanic descent had significantly smaller AD 5 cm above the bifurcation (β's = -0.59, -0.49, and -0.52, respectively, all P < 0.01), whereas AD at the bifurcation did not differ by ethnicity. Physical activity, alcohol consumption, diabetes and levels of IL-6, CRP and homocysteine were not independently associated with AD. Higher aortic and coronary artery calcium burden, but not common carotid artery intima-media thickness, were independently, but modestly (β = 0.11 to 0.19), associated with larger AD.

CONCLUSIONS

Incremental widening of the aortic diameter shared some, but not all, risk factors for occlusive vascular disease.

Thoracic Aortic Trauma: Outcomes and Hospital Resource Utilization after Endovascular and Open Repair

Thoracic endovascular aortic repair (TEVAR) has evolved as a treatment option for the management of thoracic aortic trauma as an alternative to open thoracic aortic repair (OTAR). Population-level outcomes are not known and were evaluated. Secondary data analysis of the 2005–2006 Nationwide Inpatient Sample data was performed, and 1,561 patients with thoracic aortic injury (mean age 44.8 ± 18.8 years; men 77.2%) were identified. Of these, 510 underwent emergent surgical intervention: 240 OTAR (47%) and 270 TEVAR (53%). Males were more likely to undergo any surgery (77.2% vs 22.8%; p = .03). Hospital mortality after OTAR was greater compared to TEVAR (14.61% vs 7.43%; p = .009). OTAR patients were more likely to have pulmonary complications (37.8% vs 21.65; p < .0001) but were less likely to have stroke (2.1% vs 5.8%; p = .03) compared to TEVAR patients. After adjustment, OTAR patients remained more likely to die compared to TEVAR patients (OR 11.5; 95% CI 4.0–33.2). Hospital length of stay and hospital cost were significantly greater for OTAR than for TEVAR. An increase in patients with thoracic aortic injury undergoing repair was found (23.0% vs 40.3%; p < .0002). In trauma, TEVAR was associated with decreased hospital mortality, hospital use, and pulmonary complications but increased rates of stroke. Further implementation of TEVAR for management of thoracic aortic trauma may improve future outcomes and reduce hospital resource use.

Primary payer status affects mortality for major surgical operations

OBJECTIVES

Medicaid and Uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes following major surgical operations in the United States is dependent on primary payer status.

METHODS

From 2003 to 2007, 893,658 major surgical operations were evaluated using the Nationwide Inpatient Sample (NIS) database: lung resection, esophagectomy, colectomy, pancreatectomy, gastrectomy, abdominal aortic aneurysm repair, hip replacement, and coronary artery bypass. Patients were stratified by primary payer status: Medicare (n = 491,829), Medicaid (n = 40,259), Private Insurance (n = 337,535), and Uninsured (n = 24,035). Multivariate regression models were applied to assess outcomes.

RESULTS

Unadjusted mortality for Medicare (4.4%; odds ratio [OR], 3.51), Medicaid (3.7%; OR, 2.86), and Uninsured (3.2%; OR, 2.51) patient groups were higher compared to Private Insurance groups (1.3%, P < 0.001). Mortality was lowest for Private Insurance patients independent of operation. After controlling for age, gender, income, geographic region, operation, and 30 comorbid conditions, Medicaid payer status was associated with the longest length of stay and highest total costs (P < 0.001). Medicaid (P < 0.001) and Uninsured (P < 0.001) payer status independently conferred the highest adjusted risks of mortality.

CONCLUSIONS

Medicaid and Uninsured payer status confers increased risk-adjusted mortality. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors or operation. These differences serve as an important proxy for larger socioeconomic and health system-related issues that could be targeted to improve surgical outcomes for US Patients.