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Hernandez-Morgan M, Stypula C, Fischer M, Grogan T, Neelankavil J. Impact of the Affordable Care Act on Disparities in Access to and Outcomes After Coronary Artery Bypass Grafting. J Racial Ethn Health Disparities 2023; 10:2783-2791. [PMID: 36385240 PMCID: PMC10645606 DOI: 10.1007/s40615-022-01455-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/21/2022] [Accepted: 11/07/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of this study was to examine the effect of implementation of the Affordable Care Act's Medicaid expansion on access to and outcomes after coronary artery bypass grafting (CABG) surgery. METHODS Retrospective observational study utilizing the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) from 2011 to 2016. The southern region of the USA was used as a control and the western region as the implementation group. Univariate regression models and interrupted time series models were created to evaluate and assess the impact of the Affordable Care Act's Medicaid expansion on mortality after CABG with respect to patient race. RESULTS From 2011 to 2016, a total of 117,819 isolated CABG operations were identified in the specified regions using the HCUP NIS. Of these, 89,918 were performed in the southern region, and the remainder were performed in the western region. The proportion of African American patients with Medicaid increased significantly in the western region after the ACA Medicaid expansion, from 13.1 to 17.6%, p = 0.034. There was no significant increase seen in the number of African American patients with Medicaid in the southern region. We found that overall, Black patients had higher mortality after CABG as compared to white patients (OR 1.15, p = 0.02); however, when broken down by region we found higher mortality among African American patients in the southern region only, with no statistically significant difference in mortality between white and Black patients in the western region. CONCLUSIONS Implementation of the Affordable Care Act increased access to Medicaid among Black Americans but did not necessarily decrease the disparity in access to CABG or mortality after CABG between Black and white patients. When it comes to racial disparities in mortality after CABG, there are significant regional and geographic variations which have not been previously described. This finding has important implications for the development of policy and other strategies that aim to reduce these disparities.
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Affiliation(s)
- Marisa Hernandez-Morgan
- Division of Cardiac Anesthesiology, Los Angeles, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA, USA.
| | - Christine Stypula
- Division of Cardiac Anesthesiology, Los Angeles, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA, USA
| | - Matthew Fischer
- Division of Cardiac Anesthesiology, Los Angeles, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA, USA
| | - Tristan Grogan
- Division of Cardiac Anesthesiology, Los Angeles, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA, USA
| | - Jacques Neelankavil
- Division of Cardiac Anesthesiology, Los Angeles, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA, USA
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Munigala S, Schoenfeld AJ, Mani V, Banaag A, Umoh A, Coles CL, Koehlmoos TP. Disparities in the use of colorectal cancer screening in a universally insured population during the COVID-19 pandemic. Cancer Med 2023; 12:18201-18210. [PMID: 37644735 PMCID: PMC10524012 DOI: 10.1002/cam4.6400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/14/2023] [Accepted: 07/22/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Despite the known efficacy of colorectal cancer (CRC) screening, the rates of individuals undergoing such testing have remained lower than target thresholds, even prior to the healthcare disruptions associated with the COVID-19 pandemic. We evaluated the impact of the COVID-19 pandemic on CRC screening within a nationally representative US population and assessed disparities in screening across racial/ethnic groups and socioeconomic (SES) strata. METHODS We performed a retrospective cross-sectional study using all eligible TRICARE beneficiaries aged 45-64 years between FY 2018 and 2021. High-risk individuals, those with a previous or current CRC diagnosis, and/or a personal/family history of colonic polyps, were excluded. The pre-COVID-19 period (September 1, 2018-March 31, 2020) was compared to the COVID-19 period (April 1, 2020-September 30, 2021). Secondary analyses were performed, evaluating the interaction between the COVID-19 time period, race, and our proxy for socioeconomic status. RESULTS During the study period, we identified 1,749,688 eligible individuals. Following the onset of the COVID-19 pandemic, CRC screening overall decreased from 34% in the pre-pandemic period to 30% following the onset of the pandemic (p < 0.001). This finding persisted even after adjusting for confounders in multivariable analysis (odds ratio [OR] for the pandemic timeframe: 0.79; 95% CI: 0.27, 0.31; p < 0.001). In the setting of SES, in the pandemic period, the odds of individuals from both Senior Enlisted (OR: 0.55; 95% CI: 0.54, 0.56) and Junior Enlisted sponsor ranks (OR: 0.27; 95% CI: 0.25, 0.30) were diminished as compared to Senior Officers. CONCLUSIONS AND RELEVANCE We found a 21% reduction in the odds of CRC screening in the context of the COVID-19 pandemic. Reductions in colonoscopies and other types of screening tests were not offset by changes in the use of at-home tests such as Cologuard.
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Affiliation(s)
- Satish Munigala
- Center for Health Services ResearchUniformed Services University of the Health SciencesBethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.BethesdaMarylandUSA
| | - Andrew J. Schoenfeld
- Department of Orthopaedic Surgery and Center for Surgery and Public HealthBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Vivitha Mani
- Center for Health Services ResearchUniformed Services University of the Health SciencesBethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.BethesdaMarylandUSA
| | - Amanda Banaag
- Center for Health Services ResearchUniformed Services University of the Health SciencesBethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.BethesdaMarylandUSA
| | - Ada Umoh
- Center for Health Services ResearchUniformed Services University of the Health SciencesBethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.BethesdaMarylandUSA
| | - Christian L. Coles
- Center for Health Services ResearchUniformed Services University of the Health SciencesBethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.BethesdaMarylandUSA
| | - Tracey Perez Koehlmoos
- Center for Health Services ResearchUniformed Services University of the Health SciencesBethesdaMarylandUSA
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Mani V, Banaag A, Munigala S, Umoh A, Schoenfeld AJ, Coles CL, Koehlmoos TP. Trends in breast cancer screening during the COVID-19 pandemic within a universally insured health system in the United States, 2017-2022. Cancer Med 2023; 12:19126-19136. [PMID: 37641528 PMCID: PMC10557872 DOI: 10.1002/cam4.6487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/31/2023] [Accepted: 08/18/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND In the United States, breast cancer is the most commonly diagnosed cancer and second leading cause of cancer death in women. Early detection through mammogram screening is instrumental in reducing mortality and incidence of disease. The COVID-19 pandemic posed unprecedented challenges to the provision of care, including delays in preventive screenings. We examined trends in breast cancer screening during the COVID-19 pandemic in a universally insured national population and evaluated rates across racial groups and socioeconomic strata. METHODS In this retrospective open cohort study, we used the Military Health System Data Repository to identify female TRICARE beneficiaries ages 40-64 at average risk for breast cancer between FY2018 and FY2022, broken down into prepandemic (September 1, 2018-February 28, 2020), early pandemic (March 1, 2020-September 30, 2020), and late pandemic periods (October 1, 2020-September 30, 2022). The primary outcome was receipt of breast cancer screening. RESULTS Screening dropped 74% in the early pandemic period and 22% in the late pandemic period, compared with the prepandemic period. Compared with White women, Asian/Pacific Islander women were less likely to receive mammograms during the late pandemic period (0.92RR; 0.90-0.93 95%CI). American Indian/Alaska Native women remained less likely to receive screenings compared with White women during the early (0.87RR; 0.80-0.94 95% CI) and late pandemic (0.94RR, 0.91-0.98 95% CI). Black women had a higher likelihood of screenings during both the early pandemic (1.10RR; 1.08-1.12 95% CI) and late pandemic (1.12RR, 1.11-1.13 95% CI) periods compared with White women. During the early and late pandemic periods, disparities by rank persisted from prepandemic levels, with a decrease in likelihood of screenings across all sponsor ranks. CONCLUSION Our results indicate the influence of race and socioeconomics on mammography screening during COVID-19. Targeted outreach and further evaluation of factors underpinning lower utilization in these populations are necessary to improve access to preventative services across the population.
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Affiliation(s)
- Vivitha Mani
- Center for Health Services ResearchUniformed Services University of the Health SciencesBethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, IncBethesdaMarylandUSA
| | - Amanda Banaag
- Center for Health Services ResearchUniformed Services University of the Health SciencesBethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, IncBethesdaMarylandUSA
| | - Satish Munigala
- Center for Health Services ResearchUniformed Services University of the Health SciencesBethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, IncBethesdaMarylandUSA
| | - Ada Umoh
- Center for Health Services ResearchUniformed Services University of the Health SciencesBethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, IncBethesdaMarylandUSA
| | - Andrew J. Schoenfeld
- Department of Orthopaedic SurgeryCenter for Surgery and Public HealthBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Christian L. Coles
- Center for Health Services ResearchUniformed Services University of the Health SciencesBethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, IncBethesdaMarylandUSA
| | - Tracey Perez Koehlmoos
- Center for Health Services ResearchUniformed Services University of the Health SciencesBethesdaMarylandUSA
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Yerke Hansen P, Macknofsky B, Busheme CE, Fomunung CK, Lavin AC, Fernandez CA, Sabesan V. Access to Total Knee Arthroplasty for Military Insured Patients. Arthroplast Today 2023; 21:101143. [PMID: 37521086 PMCID: PMC10382688 DOI: 10.1016/j.artd.2023.101143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 03/13/2023] [Accepted: 03/25/2023] [Indexed: 08/01/2023] Open
Abstract
Background Rigorous training may lead to increased rates of knee osteoarthritis and arthroplasties in military service members. Given the large numbers of arthritis and the increasing need for total joint replacements, access to appropriate care can be difficult for this population based on insurance restrictions. The aim of this study was to evaluate access to total knee arthroplasty for TRICARE patients in contracted civilian medical facilities. Methods Orthopedic surgeons contracted to perform total knee replacements in the state of Florida were identified via TRICARE's website. Investigators used a secret shopper methodology with a standardized script to request an appointment for their family member for a total knee arthroplasty using either TRICARE Select or BlueCross preferred provider organization. The appointment acceptance rates, wait times, call duration, and accuracy of the physician listing were collected. Results A total of 228 offices that perform total knee arthroplasties in Florida were successfully contacted. Overall, 43.1% of the clinics had an inaccurate online listing, and 207 (91%) were able to schedule an appointment with TRICARE, compared to 93% for BlueCross Blue Shield (P = .06). The average wait for TRICARE patients was 24 days and 18 days for BlueCross (P < .01). Call times for TRICARE patients averaged 7.2 minutes, compared to 5.2 minutes for BlueCross (P < .01). Conclusions TRICARE patients encountered longer waiting periods and inaccurate provider listings when accessing orthopedic care. Our results suggest a disparity in healthcare access for patients using TRICARE, which may result in negative health outcomes from receiving delayed care.
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Affiliation(s)
- Payton Yerke Hansen
- Charles E. Schmidt College of Medicine Florida Atlantic University, Boca Raton, FL, USA
| | - Brandon Macknofsky
- Charles E. Schmidt College of Medicine Florida Atlantic University, Boca Raton, FL, USA
| | - Cara E. Busheme
- Charles E. Schmidt College of Medicine Florida Atlantic University, Boca Raton, FL, USA
| | - Clyde K. Fomunung
- Department of Orthopaedics, JFK/University of Miami, Palm Beach, FL, USA
- Palm Beach Shoulder Service at Atlantis Orthopaedics, Lake Worth, FL, USA
| | - Alessia C. Lavin
- Department of Orthopaedics, JFK/University of Miami, Palm Beach, FL, USA
- Palm Beach Shoulder Service at Atlantis Orthopaedics, Lake Worth, FL, USA
| | - Carlos A. Fernandez
- Department of Orthopaedics, JFK/University of Miami, Palm Beach, FL, USA
- Palm Beach Shoulder Service at Atlantis Orthopaedics, Lake Worth, FL, USA
| | - Vani Sabesan
- Department of Orthopaedics, JFK/University of Miami, Palm Beach, FL, USA
- Palm Beach Shoulder Service at Atlantis Orthopaedics, Lake Worth, FL, USA
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Hammon L, Mondzelewski L, Robinson C, Milder E. Well-Child Care Disparities in U.S. Military Health System. Acad Pediatr 2023; 23:363-371. [PMID: 35918041 DOI: 10.1016/j.acap.2022.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To describe adherence rates for well-child visits among military children in the first 15 months of life and identify any disparities in adherence in a universally insured population. METHODS A retrospective cohort analysis was conducted using the Military Health System data repository which included children who were born between October 2013 and September 2016 and were eligible for TRICARE (the military health insurance program). Children were followed from zero to fifteen months of life to assess adherence with a national Health Effectiveness Data and Information Set (HEDIS) metric of 6 well visits during this period. Differences in adherence rates were evaluated across select demographic characteristics including sponsor rank, race, age, service branch, patient sex, geographic region, number of enrollment sites and provider type. Fitted logistic regression models were used to determine the probability of adherence with the HEDIS metric and identify disparities. RESULTS The final cohort included 168,830 infants. Across all variables, the mean number of well visits was 6.7 with an overall adherence rate of 86%. Child beneficiaries of junior enlisted, Black, and Air Force military members had lower adherence with the HEDIS metric. Enrollment at a single site and having a pediatrician for a primary care manager was associated with higher rates of adherence. CONCLUSIONS Sponsor rank, race, and service branch, along with provider type and number of enrollment sites were significantly associated with the probability of adherence. Further research should evaluate barriers to care that affect a universally insured population.
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Affiliation(s)
- Laura Hammon
- Department of Pediatrics (L Hammon), Naval Hospital Rota, Spain.
| | - Lisa Mondzelewski
- Department of Pediatrics (L Mondzelewski), Naval Medical Center San Diego, Calif
| | - Camille Robinson
- Division of Adolescent Medicine (C Robinson), Naval Medical Center San Diego, Calif
| | - Edmund Milder
- Division of Pediatric Infectious Diseases (E Milder), Naval Medical Center San Diego, Calif
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Dalton MK, Jarman MP, Manful A, Koehlmoos TP, Cooper Z, Weissman JS, Schoenfeld AJ. The Hidden Costs of War: Healthcare Utilization Among Individuals Sustaining Combat-related Trauma (2007-2018). Ann Surg 2023; 277:159-164. [PMID: 33651722 DOI: 10.1097/sla.0000000000004844] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to evaluate long-term healthcare requirements of American military servicemembers with combat-related injuries. SUMMARY OF BACKGROUND DATA US military conflicts since 2001 have produced the most combat casualties since Vietnam. Long-term consequences on healthcare utilization and associated costs remain unknown. METHODS We identified servicemembers who were treated for combat-related injuries between 2007 and 2011. Controls consisted of active-duty servicemembers injured in the civilian sector, without any history of combat-related trauma, matched (1:1) on year of injury, biologic sex injury severity, and age at time of injury. Surveillance was performed through 2018. Total annual healthcare expenditures were evaluated overall and then as expenditures in the first year after injury and for subsequent years. Negative binomial regression was used to identify the adjusted influence of combat injury on healthcare costs. RESULTS The combat-injured cohort consisted of 3981 individuals and we identified 3979 controls. Total healthcare utilization during the follow-up period resulted in median costs of $142,214 (IQR $61,428, $323,060) per combat-injured servicemember as compared to $50,741 (IQR $26,669, $104,134) among controls. Median expenditures, adjusted for duration of follow-up, for the combat-injured were $45,211 (IQR $18,698, $105,437). In adjusted analysis, overall costs were 30% higher (1.30; 95% confidence interval: 1.23, 1.37) for combat-injured personnel. CONCLUSION This investigation represents the longest continuous observation of healthcare utilization among individuals after combat injury and the first to assess costs. Expenditures were 30% higher for individuals injured as a result of combat-related trauma when compared to those injured in the civilian sector.
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Affiliation(s)
- Michael K Dalton
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115
| | - Molly P Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115
| | - Adoma Manful
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115
| | - Tracey P Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814; and
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115
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Smith HJ. Ethical Responsibilities of a Military to the Social Determinants of Health of its Service Members. Mil Med 2022; 187:252-256. [PMID: 35389484 DOI: 10.1093/milmed/usab554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/19/2021] [Accepted: 12/24/2021] [Indexed: 11/15/2022] Open
Abstract
A military exists in a unique position. It is an organization in which active duty members knowingly join or are conscripted into service with the understanding that there is an increased risk of mental and/or bodily harm as compared to many other occupations. However, while the nature of the profession can inherently be dangerous, it does not follow that its members be placed at undue excess risk if that risk can be reasonably avoided or reduced. Social determinants of health are one example of influences under a military's purview that impact health outcomes and well-being. Although the U.S. Military performs well across many health equity measures, disparities persist and require attention and redress. Military policies and practices deeply impact members' lives during and after service, and the durability and profundity of these effects establish the ethical grounds upon which any military policy should be structured. The ethical obligation is fortified by the extent of control a military exercises over its personnel. Taken together, these factors necessitate a concerted effort by militaries to remain cognizant of the ethical impacts of their policies and practices and to ensure focus remains on the well-being and readiness of its personnel. As such, militaries have ethical responsibilities to promote healthy social determinants of health among their service members via policies and public health measures.
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Affiliation(s)
- Hunter Jackson Smith
- Department of Emerging Infectious Diseases, U.S. Army Medical Research Directorate-Africa, Kisumu 40103, Kenya.,Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD 20814, USA
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Data Resources for Evaluating the Economic and Financial Consequences of Surgical Care in the United States. J Trauma Acute Care Surg 2022; 93:e17-e29. [PMID: 35358106 DOI: 10.1097/ta.0000000000003631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
LEVEL OF EVIDENCE V.
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Mooney AC, Koehlmoos T, Banaag A, Hamlin L. Severe Maternal Morbidity and 30-Day Postpartum Readmission in the Military Health System. J Womens Health (Larchmt) 2022; 31:1614-1619. [DOI: 10.1089/jwh.2021.0427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Aileen C. Mooney
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Tracey Koehlmoos
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Amanda Banaag
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Lynette Hamlin
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Racial Disparities in 30-Day Outcomes After Colorectal Surgery in an Integrated Healthcare System. J Gastrointest Surg 2022; 26:433-443. [PMID: 34581979 DOI: 10.1007/s11605-021-05151-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/09/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Racial disparities in colorectal surgery outcomes have been studied extensively in the USA, and access to healthcare resources may contribute to these differences. The Veterans Health Administration (VHA) is the largest integrated healthcare network in the USA with the potential for equal access care to veterans. The objective of this study is to evaluate the VHA for the presence of racial disparities in 30-day outcomes of patients that underwent colorectal resection. METHODS Colon and rectal resections from 2008 to 2019 were reviewed retrospectively using the Veterans Affairs Surgical Quality Improvement Program database. Patients were categorized by race and ethnicity. Multivariable analysis was used to compare 30-day outcomes. Cases with "unknown/other/declined to answer" race/ethnicity were excluded. RESULTS Thirty-six-thousand-nine-hundred-sixty-nine cases met inclusion criteria: 27,907 (75.5%) Caucasian, 6718 (18.2%) African American, 2047 (5.5%) Hispanic, and 290 (0.8%) Native American patients. There were no statistically significant differences in overall complication incidence or mortality between all cohorts. Compared to Caucasian race, African American patients had longer mean length of stay (10.7 days vs. 9.7 days; p < 0.001). Compared to Caucasian race, Hispanic patients had higher odds of pulmonary-specific complications (adjusted odds ratio with 95% confidence interval = 1.39 [1.17-1.64]; p < 0.001). CONCLUSIONS The VHA provides the benefits of integrated healthcare and access, which may explain the improvements in racial disparities compared to existing literature. However, some racial disparities in clinical outcomes still persisted in this analysis. Further efforts beyond healthcare access are needed to mitigate disparities in colorectal surgery. CLASSIFICATIONS: [Outcomes]; [Database]; [Veterans]; [Colorectal Surgery]; [Morbidity]; [Mortality].
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11
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Koehlmoos TP, Korona-Bailey J, Janvrin ML, Madsen C. Racial Disparities in the Military Health System: A Framework Synthesis. Mil Med 2021; 187:e1114-e1121. [PMID: 34910808 DOI: 10.1093/milmed/usab506] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/25/2021] [Accepted: 12/11/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Racial disparities in health care are a well-documented phenomenon in the USA. Universal insurance has been suggested as a solution to mitigate these disparities. We examined race-based disparities in the Military Health System (MHS) by constructing and analyzing a framework of existing studies that measured disparities between direct care (care provided by military treatment facilities) and private sector care (care provided by civilian health care facilities). MATERIALS AND METHODS We conducted a framework synthesis on 77 manuscripts published in partnership with the Comparative Effectiveness and Provider-Induced Demand Collaboration Project that use MHS electronic health record data to present an overview of racial disparities assessed for multiple treatment interventions in a nationally representative, universally insured population. RESULTS We identified 32 studies assessing racial disparities in areas of surgery, trauma, opioid prescription and usage, women's health, and others. Racial disparities were mitigated in postoperative complications, trauma care, and cancer screenings but persisted in diabetes readmissions, opioid usage, and minimally invasive women's health procedures. CONCLUSION Universal coverage mitigates many, but not all, racial disparities in health care. An examination of a broader range of interventions, a closer look at variation in care provided by civilian facilities, and a look at the quality of care by race provide further opportunities for research.
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Affiliation(s)
- Tracey Pérez Koehlmoos
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA
| | - Jessica Korona-Bailey
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| | - Miranda Lynn Janvrin
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| | - Cathaleen Madsen
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
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Young JM, Stahlman SL, Clausen SS, Bova ML, Mancuso JD. Racial and Ethnic Disparities in COVID-19 Infection and Hospitalization in the Active Component US Military. Am J Public Health 2021; 111:2194-2201. [PMID: 34878873 PMCID: PMC8667833 DOI: 10.2105/ajph.2021.306527] [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] [Accepted: 08/16/2021] [Indexed: 11/04/2022]
Abstract
Objectives. To assess COVID-19 disparities in the active component US military with an emphasis on race and ethnicity. Methods. In this retrospective cohort study, we calculated the incidence of COVID-19 testing, infection, and hospitalization in the active component US military in calendar year 2020. Results. Overall, 61.3 per 100 population per year were tested for COVID-19, 10.4% of tests were positive, and 1.1% of infected individuals were hospitalized. Non-Hispanic Blacks and Hispanics had a rate of testing for COVID-19 similar to that of Whites but had a higher risk of infection (adjusted risk ratio [ARR] = 1.25 and 1.26, respectively) and hospitalization (ARR = 1.28 and 1.21, respectively). Conclusions. Although of lower magnitude than seen in civilian populations, racial and ethnic disparities in COVID-19 infection and hospitalizations exist in the US military despite universal eligibility for health care, similar rate of testing, and adjustment for comorbidities and other factors. Simply making health care coverage available may be insufficient to ensure health equity. Interventions to mitigate disparities in the US military should target the patient, provider, health care system, and society at large. (Am J Public Health. 2021;111(12):2194-2201. https://doi.org/10.2105/AJPH.2021.306527).
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Affiliation(s)
- John M Young
- John M. Young and James D. Mancuso are with the Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD. Shauna L. Stahlman, Shawn S. Clausen, and Mark L. Bova are with the Epidemiology and Analysis Section of the Armed Forces Health Surveillance Division at the Defense Health Agency, Silver Spring, MD. Note. The opinions and assertions expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense or the US government
| | - Shauna L Stahlman
- John M. Young and James D. Mancuso are with the Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD. Shauna L. Stahlman, Shawn S. Clausen, and Mark L. Bova are with the Epidemiology and Analysis Section of the Armed Forces Health Surveillance Division at the Defense Health Agency, Silver Spring, MD. Note. The opinions and assertions expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense or the US government
| | - Shawn S Clausen
- John M. Young and James D. Mancuso are with the Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD. Shauna L. Stahlman, Shawn S. Clausen, and Mark L. Bova are with the Epidemiology and Analysis Section of the Armed Forces Health Surveillance Division at the Defense Health Agency, Silver Spring, MD. Note. The opinions and assertions expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense or the US government
| | - Mark L Bova
- John M. Young and James D. Mancuso are with the Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD. Shauna L. Stahlman, Shawn S. Clausen, and Mark L. Bova are with the Epidemiology and Analysis Section of the Armed Forces Health Surveillance Division at the Defense Health Agency, Silver Spring, MD. Note. The opinions and assertions expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense or the US government
| | - James D Mancuso
- John M. Young and James D. Mancuso are with the Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD. Shauna L. Stahlman, Shawn S. Clausen, and Mark L. Bova are with the Epidemiology and Analysis Section of the Armed Forces Health Surveillance Division at the Defense Health Agency, Silver Spring, MD. Note. The opinions and assertions expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense or the US government
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Zogg CK, Lichtman JH, Dalton MK, Learn PA, Schoenfeld AJ, Perez Koehlmoos T, Weissman JS, Cooper Z. In defense of Direct Care: Limiting access to military hospitals could worsen quality and safety. Health Serv Res 2021; 57:723-733. [PMID: 34608642 PMCID: PMC9264466 DOI: 10.1111/1475-6773.13885] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 07/24/2021] [Accepted: 09/20/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Ongoing health care reforms within the US Military Health System (MHS) are expected to shift >1.9 million MHS beneficiaries from military treatment facilities (MTFs) into local civilian hospitals over the next 1-2 years. The objective of this study was to examine how such health care reforms are likely to affect the quality of MHS care. DATA SOURCES Adult MHS beneficiaries, aged 18-64 years, treated in MTFs (under a program known as Direct Care) were compared against (1) MHS beneficiaries treated in locally available civilian hospitals (under a program known as Purchased Care) and (2) similarly-aged adult civilian patients across the United States. MHS beneficiaries in Direct and Purchased Care were identified from fiscal-year 2016-2018 MHS inpatient claims. National inpatients were identified in the 2017 Nationwide Readmissions Database. STUDY DESIGN Retrospective cohort. DATA COLLECTION Differences in quality were compared using two sets of quality metrics endorsed by the US Agency for Healthcare Research and Quality (AHRQ): Inpatient Quality Indicators, 19 quality metrics that look at differences in in-hospital mortality, and Patient Safety Indicators, 18 quality metrics that look at differences in in-hospital morbidity and adverse events. Among MHS beneficiaries (Direct and Purchased Care), we further simulated what changes in quality indicators might look like under various proposed scenarios of reduced access to Direct Care. PRINCIPAL FINDINGS A total of 502,252 MHS admissions from 37 MTFs and surrounding civilian hospitals were included (326,076 Direct Care, 179,176 Purchased Care). Nationwide, 9.34 million adult admissions from 2453 hospitals were included. On average, MHS beneficiaries treated in MTFs experienced better inpatient quality and improved patient safety compared with MHS beneficiaries treated in locally available civilian hospitals (e.g., summary observed-to-expected ratio for medical mortality: 0.98 vs. 1.03, p < 0.001) and adult patients across the United States (0.98 vs. 1.02, p < 0.001). Simulations of proposed changes resulted in consistently worse outcomes for MHS patients, whether reducing MTF access by 10%, 20%, or 50% nationwide; limiting MTF access to active-duty beneficiaries; or closing MTFs with the worst performance on patient safety (p < 0.001 for overall quality indicators for each). CONCLUSIONS Reducing access to MTFs could result in significant harm to MHS patients. The results underscore the importance of health-policy planning based on evidence-based evaluation and the need to consider the consequential downstream effects caused by changes in access to care.
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Affiliation(s)
- Cheryl K Zogg
- Yale School of Medicine, New Haven, Connecticut, USA.,Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Judith H Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Michael K Dalton
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Peter A Learn
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Tracey Perez Koehlmoos
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
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14
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Dalton MK, Manful A, Jarman MP, Pisano AJ, Learn PA, Koehlmoos TP, Weissman JS, Cooper Z, Schoenfeld AJ. Long-term prescription opioid use among US military service members injured in combat. J Trauma Acute Care Surg 2021; 91:S213-S220. [PMID: 34324474 DOI: 10.1097/ta.0000000000003133] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION During the Global War on Terrorism, many US Military service members sustained injuries with potentially long-lasting functional limitations and chronic pain. We sought to understand the patterns of prescription opioid use among service members injured in combat. METHODS We queried the Military Health System Data Repository to identify service members injured in combat between 2007 and 2011. Sociodemographics, injury characteristics, treatment information, and costs of care were abstracted for all eligible patients. We surveyed for prescription opioid utilization subsequent to hospital discharge and through 2018. Negative binomial regression was used to identify factors associated with cumulative prescription opioid use. RESULTS We identified 3,981 service members with combat-related injuries presenting during the study period. The median age was 24 years (interquartile range [IQR], 22-29 years), 98.5% were male, and the median follow-up was 3.3 years. During the study period, 98% (n = 3,910) of patients were prescribed opioids at least once and were prescribed opioids for a median of 29 days (IQR, 9-85 days) per patient-year of follow-up. While nearly all patients (96%; n = 3,157) discontinued use within 6 months, 91% (n = 2,882) were prescribed opioids again after initially discontinuing opioids. Following regression analysis, patients with preinjury opioid exposure, more severe injuries, blast injuries, and enlisted rank had higher cumulative opioid use. Patients who discontinued opioids within 6 months had an unadjusted median total health care cost of US $97,800 (IQR, US $42,364-237,135) compared with US $230,524 (IQR, US $134,387-370,102) among those who did not discontinue opioids within 6 months (p < 0.001). CONCLUSION Nearly all service members injured in combat were prescribed opioids during treatment, and the vast majority experienced multiple episodes of prescription opioid use. Only 4% of the population met the criteria for sustained prescription opioid use at 6 months following discharge. Early discontinuation may not translate to long-term opioid cessation in this population. LEVEL OF EVIDENCE Epidemiology study, level III.
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Affiliation(s)
- Michael K Dalton
- From the Center for Surgery and Public Health, Department of Surgery (M.K.D., A.M., M.P.J., J.S.W., Z.C., A.J.S.) and Department of Orthopedic Surgery (A.J.P., A.J.S.), Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery (P.A.L.) and Department of Preventive Medicine and Biostatistics (T.P.K.), F. Edward Hébert School of Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland
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15
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Haag A, Cone EB, Wun J, Herzog P, Lyon S, Nabi J, Marchese M, Friedlander DF, Trinh QD. Trends in Surgical Volume in the Military Health System-A Potential Threat to Mission Readiness. Mil Med 2021; 186:646-650. [PMID: 33326571 DOI: 10.1093/milmed/usaa543] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/15/2020] [Accepted: 11/26/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION The Military Health System (MHS) is tasked with a dual mission both to provide medical services for covered patients and to ensure that its active duty medical personnel maintain readiness for deployment. Knowledge, skills, and attitudes (KSA) is a metric evaluating the transferrable skills incorporated into a given surgery or medical procedure that are most relevant for surgeons deployed to a theatre of war. Procedures carrying a high KSA value are those utilizing skills with high relevance for maintaining deployment readiness. Given ongoing concerns regarding surgical volumes at MTFs and the potential adverse impact on military surgeon mission readiness were high-value surgeries to be lost to the civilian sector, we evaluated trends in the setting of high-value surgeries for beneficiaries within the MHS. METHODS We retrospectively analyzed inpatient admissions data from MTFs and TRICARE claims data from civilian hospitals, 2005-2019, to identify TRICARE-covered patients covered under "purchased care" (referred to civilian facilities) or receiving "direct care" (undergoing treatment at MTFs) and undergoing seven high-value/high-KSA surgeries: colectomy, pancreatectomy, hepatectomy, open carotid endarterectomy, abdominal aortic aneurysm (AAA) repair, esophagectomy, and coronary artery bypass grafting (CABG). Overall and procedure-specific counts were captured, MTFs were categorized into quartiles by volume, and independence between trends was tested with a Cochran-Armitage test, hypothesizing that the proportion of cases referred for purchased care was increasing. RESULTS We captured 292,411 cases, including 7,653 pancreatectomies, 4,177 hepatectomies, 3,815 esophagectomies, 112,684 colectomies, 92,161 CABGs, 26,893 AAA repairs, and 45,028 carotid endarterectomies. The majority of cases included were referred for purchased care (90.3%), with the proportion of cases referred increasing over the study period (P < .01). By procedure, all cases except AAA repairs were increasingly referred for treatment over the study period (all P < .01, except esophagectomy P = .04). On examining volume, we found that even the highest-volume-quartile MTFs performed a median of less than one esophagectomy, hepatectomy, or pancreatectomy per month. The only included procedure performed once a month or more at the majority of MTFs was CABG. CONCLUSION On examining volume and referral trends for high-value surgeries within the MHS, we found low surgical volumes at the vast majority of included MTFs and an increasing proportion of cases referred to civilian hospitals over the last 15 years. Our findings illustrate missed opportunities for maintaining the mission readiness of military surgical personnel. Prioritizing the recapture of lost surgical volume may improve the surgical teams' mission readiness.
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Affiliation(s)
- Austin Haag
- Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Eugene B Cone
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02114, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Jolene Wun
- Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Peter Herzog
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Samuel Lyon
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Junaid Nabi
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02114, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Maya Marchese
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - David F Friedlander
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02114, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Quoc-Dien Trinh
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA 02114, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02114, USA
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16
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Chaudhary MA, Dalton MK, Koehlmoos TP, Schoenfeld AJ, Goralnick E. Identifying Patterns and Predictors of Prescription Opioid Use After Total Joint Arthroplasty. Mil Med 2021; 186:587-592. [PMID: 33484147 DOI: 10.1093/milmed/usaa573] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/20/2020] [Accepted: 12/18/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Total hip arthroplasty and total knee arthroplasty account for over 1 million procedures annually. Opioids are the mainstay of postoperative pain management for these patients. In this context, the objective of this study was to determine patterns of use and factors associated with early discontinuation of opioids after total joint arthroplasty (TJA). METHODS TRICARE claims data (2006-2014) were queried for adult (18-64 years) patients who underwent total hip arthroplasty or total knee arthroplasty. Prescription opioid use was identified from 6 months before and 6 months after surgical intervention. Prior opioid use was categorized as naïve, exposed (with non-sustained use), and sustained (6 month continuous use before surgery). Cox proportional-hazards models were used to identify factors associated with opioid discontinuation following TJA. RESULTS Among the 29,767 patients included in the study, 15,271 (51.3%) had prior opioid exposure and 3,740 (12.5%) were sustained opioid users. At 6 months after the surgical intervention, 3,171 (10.6%) continued opioid use, 3.3% were among opioid naïve, 10.2% among exposed, and 33.3% among sustained users. In risk-adjusted models, prior opioid exposure (hazards ratio: 0.65, 95% CI: 0.62-0.67) and sustained prior use (hazards ratio: 0.33, 95% CI: 0.31-0.35) were the strongest predictors of lower likelihood of opioid discontinuation. Lower socio-economic status, depression, and anxiety were also strong predictors. CONCLUSION Prior opioid exposure was strongly associated with continued opioid dependence after TJA. Although one-third of prior sustained users continued use after surgery, approximately 10% of previously exposed patients became sustained users, making them the prime candidates for targeted interventions to reduce the likelihood of sustained opioid use after TJA.
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Affiliation(s)
- Muhammad Ali Chaudhary
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.,Department of Family Medicine, WellSpan Good Samaritan Hospital, Lebanon, PA 17042, USA
| | - Michael K Dalton
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Tracey P Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Eric Goralnick
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
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17
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Hamlin L, Grunwald L, Sturdivant RX, Koehlmoos TP. Comparison of Nurse-Midwife and Physician Birth Outcomes in the Military Health System. Policy Polit Nurs Pract 2021; 22:105-113. [PMID: 33615908 DOI: 10.1177/1527154421994071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study is to identify the socioeconomic and demographic characteristics of women cared for by Certified Nurse-Midwives (CNMs) versus physicians in the Military Health System (MHS) and compare birth outcomes between provider types. The MHS is one of America's largest and most complex health care systems. Using the Military Health System Data Repository, this retrospective study examined TRICARE beneficiaries who gave birth during 2012-2014. Analysis included frequency of patients by perinatal services, descriptive statistics, and logistic regression analysis by provider type. To account for differences in patient and pregnancy risk, odds ratios were calculated for both high-risk and general risk population. There were 136,848 births from 2012 to 2014, and 30.8% were delivered by CNMs. Low-risk women whose births were attended by CNMs had lower odds of a cesarean birth, induction/augmentation of labor, complications of birth, postpartum hemorrhage, endometritis, and preterm birth and higher odds of a vaginal birth, vaginal birth after cesarean, and breastfeeding than women whose births were attended by physicians. These results have implications for the composition of the women's health workforce. In the MHS, where CNMs work to the fullest scope of their authority, CNMs attended almost 4 times more births than our national average. An example to other U.S. systems and high-income countries, this study adds to the growing body of evidence demonstrating that when CNMs practice to the fullest extent of their education, they provide quality health outcomes to more women.
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Affiliation(s)
- Lynette Hamlin
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States
| | - Lindsay Grunwald
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States
| | | | - Tracey P Koehlmoos
- Health Services Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States
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18
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Haag A, Nabi J, Herzog P, Kwon NK, Marchese M, Fields A, Wun J, Friedlander DF, Cone EB, Trinh QD. Is the current referral trend a threat to the Military Health System? Perioperative outcomes and costs after colorectal surgery in the Military Health System versus civilian facilities. Surgery 2021; 170:67-74. [PMID: 33494947 DOI: 10.1016/j.surg.2020.12.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 12/08/2020] [Accepted: 12/14/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND TRICARE military beneficiaries are increasingly referred for major surgeries to civilian hospitals under "purchased care." This loss of volume may have a negative impact on the readiness of surgeons working in the "direct-care" setting at military treatment facilities and has important implications under the volume-quality paradigm. The objective of this study is to assess the impact of care source (direct versus purchased) and surgical volume on perioperative outcomes and costs of colorectal surgeries. METHODS We examined TRICARE claims and medical records for 18- to 64-year-old patients undergoing major colorectal surgery from 2006 to 2015. We used a retrospective, weighted estimating equations analysis to assess differences in 30-day outcomes (mortality, readmissions, and major or minor complications) and costs (index and total including 30-day postsurgery) for colorectal surgery patients between purchased and direct care. RESULTS We included 20,317 patients, with 24.8% undergoing direct-care surgery. Mean length of stay was 7.6 vs 7.7 days for direct and purchased care, respectively (P = .24). Adjusted 30-day odds between care settings revealed that although hospital readmissions (odds ratio 1.40) were significantly higher in direct care, overall complications (odds ratio 1.05) were similar between the 2 settings. However, mean total costs between direct and purchased care differed ($55,833 vs $30,513, respectively). Within direct care, mean total costs ($50,341; 95% confidence interval $41,509-$59,173) were lower at very high-volume facilities compared to other facilities ($54,869; 95% confidence interval $47,822-$61,916). CONCLUSION Direct care was associated with higher odds of readmissions, similar overall complications, and higher costs. Contrary to common assumptions regarding volume and quality, higher volume in the direct-care setting was not associated with fewer complications.
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Affiliation(s)
- Austin Haag
- Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Junaid Nabi
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Peter Herzog
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Nicollette K Kwon
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Maya Marchese
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Adam Fields
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jolene Wun
- Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Bethesda, MD; Henry M. Jackson Foundation, Bethesda, MD
| | - David F Friedlander
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Eugene B Cone
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Enumah ZO, Canner JK, Alejo D, Warren DS, Zhou X, Yenokyan G, Matthew T, Lawton JS, Higgins RSD. Persistent Racial and Sex Disparities in Outcomes After Coronary Artery Bypass Surgery: A Retrospective Clinical Registry Review in the Drug-eluting Stent Era. Ann Surg 2020; 272:660-667. [PMID: 32932322 PMCID: PMC8491278 DOI: 10.1097/sla.0000000000004335] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the temporal trends in 30-day mortality by race group for patients undergoing coronary artery bypass grafting (CABG) between 2011 and 2018 and to investigate the effect of race and sex on postoperative outcomes after CABG. SUMMARY BACKGROUND DATA Cardiovascular diseases remain a leading cause of death in the United States with studies demonstrating increased morbidity and mortality for black and female patients undergoing surgery. In the post drug-eluting stent era, studies of racial disparities CABG are outdated. METHODS We performed a retrospective analysis of the Society for Thoracic Surgeons database for patients undergoing CABG between 2011 and 2018. Primary outcome was 30-day mortality. Secondary outcomes included postoperative length of stay, surgical site infection, sepsis, pneumonia, stroke, reoperation, reintervention, early extubation, and readmission. RESULTS The study population was comprised of 1,042,506 patients who underwent isolated CABG between 2011 and 2018. Among all races, Black patients had higher rates of preoperative comorbidities. Compared with White patients, Black patients had higher overall mortality (2.76% vs 2.19%, P < 0.001). On univariable regression, Black patients had higher rates of death, infection, pneumonia, and postoperative stroke compared to White patients. On multivariable regression, Black patients had higher odds of 30-day mortality compared to white patients [odds ratio (OR) = 1.11, 95% confidence interval (CI) 1.05-1.18]. Similarly, female patients had higher odds of death compared to males (OR = 1.26, 95% CI 1.21-1.30). CONCLUSIONS In the modern era, racial and sex disparities in mortality and postoperative morbidity after coronary bypass surgery persist with Black patients and female patients consistently experiencing worse outcomes than White male patients. Although there may be unknown or underappreciated biological mechanisms at play, future research should focus on socioeconomic, cultural, and multilevel factors.
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Affiliation(s)
| | - Joseph K. Canner
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Diane Alejo
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Daniel S. Warren
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Xun Zhou
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Gayane Yenokyan
- Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD
| | - Thomas Matthew
- Johns Hopkins Suburban Hospital, Department of Cardiac Surgery, Bethesda, MD
| | - Jennifer S. Lawton
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Robert S. D. Higgins
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
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20
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Amen TB, Varady NH, Rajaee S, Chen AF. Persistent Racial Disparities in Utilization Rates and Perioperative Metrics in Total Joint Arthroplasty in the U.S.: A Comprehensive Analysis of Trends from 2006 to 2015. J Bone Joint Surg Am 2020; 102:811-820. [PMID: 32379122 DOI: 10.2106/jbjs.19.01194] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Trends in racial disparities in total joint arthroplasty (TJA) care have been documented from 1991 to 2008. However, it remains unknown whether numerous national and orthopaedic-specific efforts to reduce these disparities have been successful. The purpose of this study was to investigate trends in racial disparities in TJA utilization and perioperative metrics between black and white patients in the U.S. from 2006 to 2015. METHODS The National Inpatient Sample (NIS) was queried to identify black and white patients who underwent primary total knee arthroplasty (TKA) or primary total hip arthroplasty (THA) between 2006 to 2015. Utilization rates, length of stay in the hospital (LOS), discharge disposition, and inpatient complications and mortality were trended over time. Linear and logistic regression analyses were performed to assess changes in disparities over time. RESULTS From 2006 to 2015, there were persistent white-black disparities in standardized utilization rates and LOS for both TKA and THA (p < 0.001 for all; ptrend > 0.05 for all). Moreover, there were worsening disparities in the rates of discharge to a facility (rather than home) after both TKA (white compared with black: 40.3% compared with 47.2% in 2006 and 25.7% compared with 34.2% in 2015, ptrend < 0.001) and THA (white compared with black: 42.6% compared with 41.7% in 2006 and 23.4% compared with 29.2% in 2015, ptrend < 0.001) and worsening disparities in complication rates after TKA (white compared with black: 5.1% compared 6.1% in 2006 and 3.9% compared with 6.0% in 2015, ptrend < 0.001). CONCLUSIONS There were persistent, and in many cases worsening, racial disparities in TJA utilization and perioperative care between black and white patients from 2006 to 2015 in the U.S. These results were despite national efforts to reduce racial disparities and highlight the need for continued focus on this issue. Although recent work has shown that elimination of racial disparities in TJA care is possible, the present study demonstrates that renewed efforts are still needed on a national level.
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Affiliation(s)
- Troy B Amen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sean Rajaee
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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21
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Nabi J, Haag AJ, Trinh QD. Accounting for Readiness—Integrating Time-Driven Activity-Based Costing (TDABC) into the Military Health System. Mil Med 2020; 185:e930-e933. [DOI: 10.1093/milmed/usaa051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/16/2020] [Accepted: 02/28/2020] [Indexed: 02/01/2023] Open
Affiliation(s)
- Junaid Nabi
- Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, 45 Francis St., ASB II-3, Boston, MA 02115
- Center for Surgery and Public Health, Brigham and Women's Hospital, 1620 Tremont St., Suite 2-016, Boston, MA 02120
| | - Austin J Haag
- Department of Preventive Medicine & Biostatistics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Quoc-Dien Trinh
- Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, 45 Francis St., ASB II-3, Boston, MA 02115
- Center for Surgery and Public Health, Brigham and Women's Hospital, 1620 Tremont St., Suite 2-016, Boston, MA 02120
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Mazzeffi M, Holmes SD, Alejo D, Fonner CE, Ghoreishi M, Pasrija C, Schena S, Metkus T, Salenger R, Whitman G, Ad N, Higgins RSD, Taylor B. Racial Disparity in Cardiac Surgery Risk and Outcome: Report From a Statewide Quality Initiative. Ann Thorac Surg 2020; 110:531-536. [PMID: 31962111 DOI: 10.1016/j.athoracsur.2019.11.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 10/02/2019] [Accepted: 11/15/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Racial disparities persist in health care. Our study objective was to evaluate racial disparity in cardiac surgery in Maryland. METHODS A statewide database was used to identify patients. Demographics, comorbidities, and predicted risk of death were compared between races. Crude mortality and incidence of complications were compared between groups, as were risk-adjusted odds for mortality and major morbidity or mortality. RESULTS The study included 23,094 patients. Most patients were white (75.8%), followed by African American (16.3%), Asian (3.8%), and other races (4.1%). African Americans had a higher preoperative risk for mortality based on The Society of Thoracic Surgeons predictive models compared with white patients (3.0% vs 2.3%, P < .001). African Americans also had higher prevalence of diabetes mellitus, hypertension, peripheral vascular disease, and cerebral vascular disease than white patients. After adjustment for preoperative risk, there was no difference in 30-day mortality between African Americans (odds ratio [OR], 1.26; 95% confidence interval [CI], 0.99-1.59), Asians (OR, 1.22; 95% CI, 0.75-1.97), and other races (OR, 1.18; 95% CI, 0.74-1.89) compared with whites. African Americans had lower risk-adjusted odds of major morbidity or mortality compared with whites (OR, 0.83; 95% CI, 0.75-0.93). CONCLUSIONS African American cardiac surgical patients have the highest preoperative risk in Maryland. Patients appeared to receive excellent cardiac surgical care, regardless of race, as risk-adjusted mortality did not differ between groups, and African American patients had lower risk-adjusted odds of major morbidity or mortality than white patients. Future interventions in Maryland should be aimed at reducing preoperative risk disparity in cardiac surgical patients.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland.
| | - Sari D Holmes
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Diane Alejo
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Clifford E Fonner
- Maryland Cardiac Surgery Quality Initiative, Inc, Baltimore, Maryland
| | - Mehrdad Ghoreishi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Chetan Pasrija
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Stefano Schena
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thomas Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rawn Salenger
- Department of Cardiothoracic Surgery, St. Joseph Medical Center, University of Maryland, Towson, Maryland
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Niv Ad
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; Department of Cardiothoracic Surgery, Washington Adventist Hospital, Takoma Park, Maryland
| | - Robert S D Higgins
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bradley Taylor
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
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