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Estrada LV, Barcelona V, Dhingra L, Luchsinger JA, Dick AW, Glance LG, Stone PW. Potentially Avoidable Hospitalizations Among Historically Marginalized Nursing Home Residents. JAMA Netw Open 2024; 7:e249312. [PMID: 38696169 PMCID: PMC11066698 DOI: 10.1001/jamanetworkopen.2024.9312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 03/04/2024] [Indexed: 05/04/2024] Open
Abstract
Importance Nursing home (NH) transfers to hospitals are common and have been associated with cognitive decline; approximately 45% of NH hospital transfers are potentially avoidable hospitalizations (PAHs). Objective To determine PAH incidence for historically marginalized NH residents with severe cognitive impairment compared with non-Hispanic White residents. Design, Setting, and Participants This cross-sectional study merged 2018 Centers for Medicaid & Medicare Services datasets and LTCFocus, a public dataset on US NH care, for US NH residents aged 65 years and older who had a hospitalization. Analyses were performed from January to May 2022. Exposure Race and ethnicity of NH residents. Main Outcomes and Measures Racial and ethnic differences in resident-level annual rates of PAHs were estimated for residents with and without severe cognitive impairment (measured using the Cognitive Function Scale), controlling for resident characteristics, comorbidities, dual eligibility, and time at risk. PAHs were defined as NH hospital transfers that resulted from neglectful NH care or for which NH treatment would have been appropriate. Results Of 2 098 385 NH residents nationwide included in the study, 7151 (0.3%) were American Indian or Alaska Native, 39 873 (1.9%) were Asian, 229 112 (10.9%) were Black or African American, 99 304 (4.7%) were Hispanic, 2785 (0.1%) were Native Hawaiian or Pacific Islander, 1 713 670 (81.7%) were White, and 6490 (0.3%) were multiracial; 1 355 143 (64.6%) were female; 128 997 (6.2%) were severely cognitively impaired; and the mean (SD) age was 81.8 (8.7) years. PAH incidence rate ratios (IRRs) were significantly greater for residents with severe cognitive impairment compared with those without. In unadjusted analyses comparing historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment, American Indian or Alaska Native residents had a 49% higher PAH incidence (IRR, 1.49 [95% CI, 1.10-2.01]), Black or African American residents had a 64% higher incidence (IRR, 1.64 [95% CI, 1.48-1.81]), and Hispanic residents had a 45% higher incidence (IRR, 1.45 [95% CI, 1.29-1.62]). Higher incidences persisted for historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment in adjusted analyses. Asian residents had a 24% higher PAH incidence (IRR, 1.24 [95% CI, 1.06-1.45]), Black or African American residents had a 48% higher incidence (IRR, 1.48 [95% CI, 1.36-1.60]), and Hispanic residents had a 27% higher incidence (IRR, 1.27 [95% CI, 1.16-1.39]). Conclusions and Relevance In this cross-sectional study of PAHs, compared with non-Hispanic White NH residents, historically marginalized residents had increased PAH incidence. In the presence of severe cognitive impairment, incidence rates increased significantly compared with rates for residents without severe cognitive impairment. These results suggest that identification of residents with severe cognitive impairment and proper NH care may help prevent further cognitive decline by avoiding PAHs.
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Affiliation(s)
- Leah V. Estrada
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, New York
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - José A. Luchsinger
- Departments of Medicine and Epidemiology, Columbia University Irving Medical Center
| | | | - Laurent G. Glance
- RAND Corporation, Boston, Massachusetts
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York
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Panda K, Glance LG, Mazzeffi M, Gu Y, Wood KL, Moitra VK, Wu IY. Perioperative Extracorporeal Cardiopulmonary Resuscitation in Adult Patients: A Review for the Perioperative Physician. Anesthesiology 2024; 140:1026-1042. [PMID: 38466188 DOI: 10.1097/aln.0000000000004916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
The use of extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest has grown rapidly over the previous decade. Considerations for the implementation and management of extracorporeal cardiopulmonary resuscitation are presented for the perioperative physician.
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Affiliation(s)
- Kunal Panda
- Division of Cardiac Anesthesiology, Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Laurent G Glance
- Division of Cardiac Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York; and RAND Health, Boston, Massachusetts
| | - Michael Mazzeffi
- Division of Cardiothoracic Anesthesiology, Division of Critical Care Medicine, Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Yang Gu
- Division of Cardiac Anesthesiology, Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Katherine L Wood
- Division of Cardiac Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Vivek K Moitra
- Division of Critical Care Medicine, Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Isaac Y Wu
- Division of Cardiac Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
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Kang JA, Stone PW, Glance LG, Dick AW. The association of nursing home infection preventionists' training and credentialing with resident COVID 19 deaths. J Am Geriatr Soc 2024; 72:1070-1078. [PMID: 38241196 PMCID: PMC11018459 DOI: 10.1111/jgs.18760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 11/17/2023] [Accepted: 12/16/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Nursing home (NH) residents' vulnerability to COVID-19 underscores the importance of infection preventionists (IPs) within NHs. Our study aimed to determine whether training and credentialing of NH IPs were associated with resident COVID-19 deaths. METHODS This retrospective observational study utilized data from the Centers for Disease Control and Prevention's National Healthcare Safety Network NH COVID-19 Module and USAFacts, from May 2020 to February 2021, linked to a 2018 national NH survey. We categorized IP personnel training and credentialing into four groups: (1) LPN without training; (2) RN/advanced clinician without training; (3) LPN with training; and (4) RN/advanced clinician with training. Multivariable linear regression models of facility-level weekly deaths per 1000 residents as a function of facility characteristics, and county-level COVID-19 burden (i.e., weekly cases or deaths per 10,000 population) were estimated. RESULTS Our study included 857 NHs (weighted n = 14,840) across 489 counties and 50 states. Most NHs had over 100 beds, were for profit, part of chain organizations, and located in urban areas. Approximately 53% of NH IPs had infection control training and 82% were RNs/advanced clinicians. Compared with NHs employing IPs who were LPNs without training, NHs employing IPs who were RNs/advanced clinicians without training had lower weekly COVID-19 death rates (-1.04 deaths per 1000 residents; 95% CI -1.90, -0.18), and NHs employing IPs who were LPNs with training had lower COVID-19 death rates (-1.09 deaths per 1000 residents; 95% CI -2.07, -0.11) in adjusted models. CONCLUSIONS NHs with LPN IPs without training in infection control had higher death rates than NHs with LPN IPs with training in infection control, or NHs with RN/advanced clinicians in the IP role, regardless of IP training. IP training of RN/advanced clinician IPs was not associated with death rates. These findings suggest that efforts to standardize and improve IP training may be warranted.
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Affiliation(s)
- Jung A. Kang
- Center for Health Policy, Columbia University School of Nursing, 560 West 168 Street, New York, NY 10032
| | - Patricia W. Stone
- Center for Health Policy, Columbia University School of Nursing, 560 West 168 Street, New York, NY 10032
| | - Laurent G. Glance
- Health Unit, RAND Corporation, 20 Park Plaza, Suite 920, Boston, MA, 02116
- Departments of Anesthesiology and Perioperative Medicine; Public Health Sciences, University of Rochester School of Medicine, Rochester, NY
| | - Andrew W. Dick
- Health Unit, RAND Corporation, 20 Park Plaza, Suite 920, Boston, MA, 02116
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Sekeres G, Miller TR, Mariano ER, Glance LG, Sun EC. Association between Anesthesia Group Size and Merit-Based Incentive Payment System Scores. Anesthesiology 2024; 140:853-855. [PMID: 38470114 DOI: 10.1097/aln.0000000000004887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Affiliation(s)
| | | | | | | | - Eric C Sun
- Stanford University School of Medicine, Palo Alto, California (E.C.S.).
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Glance LG, Maddox KEJ, Mazzeffi M, Shippey E, Wood KL, Furuya EY, Stone PW, Shang J, Wu IY, Gosev I, Lustik SJ, Lander HL, Wyrobek JA, Laserna A, Dick AW. Insurance-Based Disparities in Outcomes and ECMO Utilization for Hospitalized COVID-19 Patients. Anesthesiology 2024:139982. [PMID: 38526387 DOI: 10.1097/aln.0000000000004985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
BACKGROUND The objective of this study was to examine insurance-based disparities in mortality, non-home discharges, and ECMO utilization in patients hospitalized with COVID-19. METHODS Using a national database of U.S. academic medical centers and their affiliated hospitals, the risk-adjusted association between mortality, non-home discharge, and ECMO utilization and (1) the type of insurance coverage (private insurance, Medicare, dual enrollment in Medicare and Medicaid, and no insurance) and (2) the weekly hospital COVID-19 burden (0-5.0%; 5.1-10%, 10.1-20%, 20.1-30%, 30.1%-) was evaluated. Modelling was expanded to include an interaction between payer status and the weekly hospital COVID-19 burden to examine whether the lack of private insurance was associated with increases in disparities as the COVID-19 burden increased. RESULTS Among 760,846 patients hospitalized with COVID-19, 214,992 had private insurance, 318,624 had Medicare, 96,192 were dually enrolled in Medicare and Medicaid, 107,548 had Medicaid, and 23,560 had no insurance. Overall, 76,250 died, 211,702 had non-home discharges, 75,703 were mechanically ventilated, and 2,642 underwent ECMO. The adjusted odds of death were higher in patients with Medicare (aOR 1.28; [95% CI: 1.21, 1.35]; P<0.0005), dually enrolled (aOR, 1.39; [1.30, 1.50]; P<0.0005), Medicaid (aOR, 1.28; [1.20, 1.36]; P<0.0005), and no insurance (aOR, 1.43; [1.26, 1.62]; P<0.0005) compared to patients with private insurance. Patients with Medicare (aOR, 0.47; [CI: 0.39, 0.58]; P <0.0005), dually enrolled (aOR, 0.32; [0.24, 0.43]; P<0.0005), Medicaid (aOR, 0.70; [ 0.62, 0.79]; P<0.0005), and no insurance (aOR, 0.40; [0.29, 0.56]; P<0.001] were less likely to be placed on ECMO than patients with private insurance. Mortality, non-home discharges, and ECMO utilization did not change significantly more in patients with private insurance compared to patients without private insurance as the COVID-19 burden increased. CONCLUSION Among patients with COVID-19, insurance-based disparities in mortality, non-home discharges, and ECMO utilization were substantial, but these disparities did not increase as the hospital COVID-19 burden increased.
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Affiliation(s)
- Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, NY
- RAND Health, RAND, Boston, MA
| | - Karen E Joynt Maddox
- Department of Medicine, Washington University in St. Louis, St. Louis, MO
- Center for Health Economics and Policy at the Institute for Public Health, Washington University in St. Louis, St. Louis, MO
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | | | - Katherine L Wood
- Department of Surgery (Cardiac), University of Rochester School of Medicine, Rochester, NY
| | - E Yoko Furuya
- Department of Medicine, Division of Infectious Diseases Columbia University Irving Medical Center, New York, NY
| | - Patricia W Stone
- Columbia School of Nursing, Center for Health Policy, New York, NY
| | - Jingjing Shang
- Columbia School of Nursing, Center for Health Policy, New York, NY
| | - Isaac Y Wu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY
| | - Igor Gosev
- Department of Surgery (Cardiac), University of Rochester School of Medicine, Rochester, NY
| | - Stewart J Lustik
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY
| | - Heather L Lander
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY
| | - Julie A Wyrobek
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY
| | - Andres Laserna
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY
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Glance LG, Benesch CG, Joynt Maddox KE, Bender MT, Shang J, Stone PW, Lustik SJ, Nadler JW, Galton C, Dick AW. Was COVID-19 Associated With Worsening Inequities in Stroke Treatment and Outcomes? J Am Heart Assoc 2023; 12:e031221. [PMID: 37750574 PMCID: PMC10727248 DOI: 10.1161/jaha.123.031221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/18/2023] [Indexed: 09/27/2023]
Abstract
Background COVID-19 stressed hospitals and may have disproportionately affected the stroke outcomes and treatment of Black and Hispanic individuals. Methods and Results This retrospective study used 100% Medicare Provider Analysis and Review file data from between 2016 and 2020. We used interrupted time series analyses to examine whether the COVID-19 pandemic exacerbated disparities in stroke outcomes and reperfusion therapy. Among 1 142 560 hospitalizations for acute ischemic strokes, 90 912 (8.0%) were Hispanic individuals; 162 752 (14.2%) were non-Hispanic Black individuals; and 888 896 (77.8%) were non-Hispanic White individuals. The adjusted odds of mortality increased by 51% (adjusted odds ratio [aOR], 1.51 [95% CI, 1.34-1.69]; P<0.001), whereas the rates of nonhome discharges decreased by 11% (aOR, 0.89 [95% CI, 0.82-0.96]; P=0.003) for patients hospitalized during weeks when the hospital's proportion of patients with COVID-19 was >30%. The overall rates of motor deficits (P=0.25) did not increase, and the rates of reperfusion therapy did not decrease as the weekly COVID-19 burden increased. Black patients had lower 30-day mortality (aOR, 0.70 [95% CI, 0.69-0.72]; P<0.001) but higher rates of motor deficits (aOR, 1.14 [95% CI, 1.12-1.16]; P<0.001) than White individuals. Hispanic patients had lower 30-day mortality and similar rates of motor deficits compared with White individuals. There was no differential increase in adverse outcomes or reduction in reperfusion therapy among Black and Hispanic individuals compared with White individuals as the weekly COVID-19 burden increased. Conclusions This national study of Medicare patients found no evidence that the hospital COVID-19 burden exacerbated disparities in treatment and outcomes for Black and Hispanic individuals admitted with an acute ischemic stroke.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative MedicineUniversity of Rochester School of MedicineRochesterNY
- Department of Public Health SciencesUniversity of Rochester School of MedicineRochesterNY
- RAND Health, RANDBostonMA
| | - Curtis G. Benesch
- Department of NeurologyUniversity of Rochester School of MedicineRochesterNY
| | - Karen E. Joynt Maddox
- Department of MedicineWashington University in St. LouisSt. LouisMO
- Center for Health Economics and Policy at the Institute for Public HealthWashington University in St. LouisSt. LouisMO
| | - Matthew T. Bender
- Department of NeurosurgeryUniversity of Rochester School of MedicineRochesterNY
| | - Jingjing Shang
- Columbia School of Nursing, Center for Health PolicyNew YorkNY
| | | | - Stewart J. Lustik
- Department of Anesthesiology and Perioperative MedicineUniversity of Rochester School of MedicineRochesterNY
| | - Jacob W. Nadler
- Department of Anesthesiology and Perioperative MedicineUniversity of Rochester School of MedicineRochesterNY
| | - Christopher Galton
- Department of Anesthesiology and Perioperative MedicineUniversity of Rochester School of MedicineRochesterNY
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Glance LG, Smith DI, Joynt Maddox KE. Do Anesthesiologists Have a Role in Promoting Equitable Health Care? Anesthesiology 2023; 139:244-248. [PMID: 37552097 DOI: 10.1097/aln.0000000000004672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Affiliation(s)
- Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York; Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York; RAND Health, RAND, Boston, Massachusetts
| | - Daryl I Smith
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Karen E Joynt Maddox
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri; Center for Health Economics and Policy at the Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri
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Glance LG, Joynt Maddox KE, Shang J, Stone PW, Lustik SJ, Knight PW, Dick AW. The COVID-19 Pandemic and Associated Inequities in Acute Myocardial Infarction Treatment and Outcomes. JAMA Netw Open 2023; 6:e2330327. [PMID: 37624599 PMCID: PMC10457721 DOI: 10.1001/jamanetworkopen.2023.30327] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/10/2023] [Indexed: 08/26/2023] Open
Abstract
Importance The COVID-19 pandemic disrupted usual care for emergent conditions, such as acute myocardial infarction (AMI). Understanding whether Black and Hispanic individuals experiencing AMI had greater increases in poor outcomes compared with White individuals during the pandemic has important equity implications. Objective To investigate whether the COVID-19 pandemic was associated with increased disparities in treatment and outcomes among Medicare patients hospitalized with AMI. Design, Setting, and Participants This cross-sectional study used Medicare data for patients hospitalized with AMI between January 2016 and November 2020. Patients were categorized as Hispanic, non-Hispanic Black, and non-Hispanic White. The association between race and ethnicity and outcomes as a function of the proportion of hospitalized patients with COVID-19 was evaluated using interrupted time series. Data were analyzed from October 2022 to June 2023. Exposure The main exposure was a hospital's proportion of hospitalized patients with COVID-19 on a weekly basis as a proxy for care disruption during the pandemic. Main Outcomes and Measures Revascularization, 30-day mortality, 30-day readmission, and nonhome discharges. Results A total of 1 319 273 admissions for AMI (579 817 females [44.0%]; 122 972 Black [9.3%], 117 668 Hispanic [8.9%], and 1 078 633 White [81.8%]; mean [SD] age, 77 [8.4] years) were included. For patients with non-ST segment elevation MI (NSTEMI) overall, the adjusted odds of mortality and nonhome discharges increased by 51% (adjusted odds ratio [aOR], 1.51; 95% CI, 1.29-1.76; P < .001) and 32% (aOR, 1.32; 95% CI, 1.15-1.52; P < .001), respectively, and the odds of revascularization decreased by 27% (aOR, 0.73; 95% CI, 0.64-0.83; P < .001) among patients hospitalized during weeks with a high hospital COVID-19 burden (>30%) vs patients hospitalized prior to the pandemic. Black individuals with NSTEMI experienced a clinically insignificant 7% greater increase in the odds of mortality (aOR, 1.07; 95% CI, 1.00-1.15; P = .04) for each 10% increase in the COVID-19 hospital burden but no increases in readmissions or nonhome discharges or reductions in revascularization rates compared with White individuals. There were no differential increases in adverse outcomes among Hispanic compared with White patients with NSTEMI based on hospital COVID-19 burden. Increases in hospital COVID-19 burden were not associated with changes in outcomes or the use of revascularization in STEMI overall or by racial or ethnic group. Conclusions and Relevance This study found that while hospital COVID-19 burden was associated with worse treatment and outcomes for NSTEMI, race and ethnicity-associated inequities did not increase significantly during the pandemic. These findings suggest the need for additional efforts to mitigate outcomes associated with the COVID-19 pandemic for patients admitted with AMI when the hospital COVID-19 burden is substantially increased.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| | - Karen E. Joynt Maddox
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
- Center for Health Economics and Policy at the Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri
| | - Jingjing Shang
- Center for Health Policy, Columbia University School of Nursing, New York, New York
| | - Patricia W. Stone
- Center for Health Policy, Columbia University School of Nursing, New York, New York
| | - Stewart J. Lustik
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Peter W. Knight
- Department of Surgery, Cardiac, University of Rochester School of Medicine, Rochester, New York
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Loria A, Glance LG, Melucci AD, Boodry C, Justiniano CF, Dunne RF, Mustian KM, Becerra AZ, Jusko TA, Temple LK, Fleming FJ. Low Preoperative Serum Creatinine is Common and Associated With Poor Outcomes After Nonemergent Inpatient Surgery. Ann Surg 2023; 277:246-251. [PMID: 36448909 DOI: 10.1097/sla.0000000000005760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To assess the association between low preoperative serum creatinine and postoperative outcomes. BACKGROUND The association between low creatinine and poor surgical outcomes is not well understood. METHODS We identified patients with creatinine in the 7 days preceding nonemergent inpatient surgery in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2020. Multivariable logistic regression was used to examine the association between creatinine and 30-day mortality and major complications. RESULTS Of 1,809,576 patients, 27.8% of males and 23.5% of females had low preoperative serum creatinine, 14.6% experienced complications, and 1.2% died. For males, compared with the reference creatinine of 0.85 to 1.04, those with serum creatinine ≤0.44 had 55% increased odds of mortality [ adjusted odds ratio (aOR), 1.55; 95% CI, 1.29-1.86] and 82% increased odds of major complications (aOR, 1.82; 95% CI, 1.69-1.97). Similarly, for females, compared with the reference range of 0.65 to 0.84, those with serum creatinine ≤0.44 had 49% increased odds of mortality (aOR, 1.49; 95% CI, 1.32-1.67) and 76% increased odds of major complications (aOR, 1.76; 95% CI, 1.70-1.83). These associations persisted for the total cohort, among those with mildly low albumin, and for those with creatinine values measured 8 to 30 days preoperatively. CONCLUSIONS A low preoperative creatinine is common and associated with poor outcomes after nonemergent inpatient surgery. A low creatinine may help identify high-risk patients who may benefit from further evaluation and optimization.
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Affiliation(s)
- Anthony Loria
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York.,RAND Health, Rand, Boston, MA
| | - Alexa D Melucci
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York
| | - Courtney Boodry
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York
| | - Carla F Justiniano
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York
| | - Richard F Dunne
- Department of Medicine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Karen M Mustian
- Department of Surgery, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Adan Z Becerra
- Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Todd A Jusko
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Larissa K Temple
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York
| | - Fergal J Fleming
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York
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Glance LG, Joynt Maddox KE, Mazzefi M, Knight PW, Eaton MP, Feng C, Kertai MD, Albernathy J, Wu IY, Wyrobek JA, Cevasco M, Desai N, Dick AW. Racial and Ethnic Disparities in Access to Minimally Invasive Mitral Valve Surgery. JAMA Netw Open 2022; 5:e2247968. [PMID: 36542380 PMCID: PMC9857175 DOI: 10.1001/jamanetworkopen.2022.47968] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Whether people from racial and ethnic minority groups experience disparities in access to minimally invasive mitral valve surgery (MIMVS) is not known. OBJECTIVE To investigate racial and ethnic disparities in the utilization of MIMVS. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the Society of Thoracic Surgeons Database for patients who underwent mitral valve surgery between 2014 and 2019. Statistical analysis was performed from January 24 to August 11, 2022. EXPOSURES Patients were categorized as non-Hispanic White, non-Hispanic Black, and Hispanic individuals. MAIN OUTCOMES AND MEASURES The association between MIMVS (vs full sternotomy) and race and ethnicity were evaluated using logistic regression. RESULTS Among the 103 753 patients undergoing mitral valve surgery (mean [SD] age, 62 [13] years; 47 886 female individuals [46.2%]), 10 404 (10.0%) were non-Hispanic Black individuals, 89 013 (85.8%) were non-Hispanic White individuals, and 4336 (4.2%) were Hispanic individuals. Non-Hispanic Black individuals were more likely to have Medicaid insurance (odds ratio [OR], 2.21; 95% CI, 1.64-2.98; P < .001) and to receive care from a low-volume surgeon (OR, 4.45; 95% CI, 4.01-4.93; P < .001) compared with non-Hispanic White individuals. Non-Hispanic Black individuals were less likely to undergo MIMVS (OR, 0.65; 95% CI, 0.58-0.73; P < .001), whereas Hispanic individuals were not less likely to undergo MIMVS compared with non-Hispanic White individuals (OR, 1.08; 95% CI, 0.67-1.75; P = .74). Patients with commercial insurance had 2.35-fold higher odds of undergoing MIMVS (OR, 2.35; 95% CI, 2.06-2.68; P < .001) than those with Medicaid insurance. Patients operated by very-high volume surgeons (300 or more cases) had 20.7-fold higher odds (OR, 20.70; 95% CI, 12.7-33.9; P < .001) of undergoing MIMVS compared with patients treated by low-volume surgeons (less than 20 cases). After adjusting for patient risk, non-Hispanic Black individuals were still less likely to undergo MIMVS (adjusted OR [aOR], 0.88; 95% CI, 0.78-0.99; P = .04) and were more likely to die or experience a major complication (aOR, 1.25; 95% CI, 1.16-1.35; P < .001) compared with non-Hispanic White individuals. CONCLUSIONS AND RELEVANCE In this cross-sectional study, non-Hispanic Black patients were less likely to undergo MIMVS and more likely to die or experience a major complication than non-Hispanic White patients. These findings suggest that efforts to reduce inequity in cardiovascular medicine may need to include increasing access to private insurance and high-volume surgeons.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| | - Karen E. Joynt Maddox
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
- Center for Health Economics and Policy at the Institute for Public Health, Washington University in St Louis, St Louis, Missouri
| | - Michael Mazzefi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville
| | - Peter W. Knight
- Department of Surgery, University of Rochester School of Medicine, Rochester, New York
| | - Michael P. Eaton
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Changyong Feng
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine, Rochester, New York
| | - Miklos D. Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James Albernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins, Baltimore, Maryland
| | - Isaac Y. Wu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Julie A. Wyrobek
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Marisa Cevasco
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
| | - Nimesh Desai
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
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11
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Glance LG, Vutskits L, Davidson A. Prediction Algorithms: Is Peer Review Enough? Anesthesiology 2022; 137:661-663. [PMID: 36413784 PMCID: PMC9699284 DOI: 10.1097/aln.0000000000004421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY, USA
- RAND Health, RAND, Boston, MA
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
- Geneva Neuroscience Center, University of Geneva, Geneva, Switzerland
| | - Andrew Davidson
- Department of Anaesthesia, Royal Children’s Hospital, Melbourne, Australia
- Murdoch Children’s Research Institute, Melbourne, Australia
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12
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Glance LG, Dick AW, Shippey E, McCormick PJ, Dutton R, Stone PW, Shang J, Lustik SJ, Lander HL, Gosev I, Joynt Maddox KE. Association Between the COVID-19 Pandemic and Insurance-Based Disparities in Mortality After Major Surgery Among US Adults. JAMA Netw Open 2022; 5:e2222360. [PMID: 35849395 PMCID: PMC9294995 DOI: 10.1001/jamanetworkopen.2022.22360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE The COVID-19 pandemic caused significant disruptions in surgical care. Whether these disruptions disproportionately impacted economically disadvantaged individuals is unknown. OBJECTIVE To evaluate the association between the COVID-19 pandemic and mortality after major surgery among patients with Medicaid insurance or without insurance compared with patients with commercial insurance. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the Vizient Clinical Database for patients who underwent major surgery at hospitals in the US between January 1, 2018, and May 31, 2020. EXPOSURES The hospital proportion of patients with COVID-19 during the first wave of COVID-19 cases between March 1 and May 31, 2020, stratified as low (≤5.0%), medium (5.1%-10.0%), high (10.1%-25.0%), and very high (>25.0%). MAIN OUTCOMES AND MEASURES The main outcome was inpatient mortality. The association between mortality after surgery and payer status as a function of the proportion of hospitalized patients with COVID-19 was evaluated with a quasi-experimental triple-difference approach using logistic regression. RESULTS Among 2 950 147 adults undergoing inpatient surgery (1 550 752 female [52.6%]) at 677 hospitals, the primary payer was Medicare (1 427 791 [48.4%]), followed by commercial insurance (1 000 068 [33.9%]), Medicaid (321 600 [10.9%]), other payer (140 959 [4.8%]), and no insurance (59 729 [2.0%]). Mortality rates increased more for patients undergoing surgery during the first wave of the pandemic in hospitals with a high COVID-19 burden (adjusted odds ratio [AOR], 1.13; 95% CI, 1.03-1.24; P = .01) and a very high COVID-19 burden (AOR, 1.38; 95% CI, 1.24-1.53; P < .001) compared with patients in hospitals with a low COVID-19 burden. Overall, patients with Medicaid had 29% higher odds of death (AOR, 1.29; 95% CI, 1.22-1.36; P < .001) and patients without insurance had 75% higher odds of death (AOR, 1.75; 95% CI, 1.55-1.98; P < .001) compared with patients with commercial insurance. However, mortality rates for surgical patients with Medicaid insurance (AOR, 1.03; 95% CI, 0.82-1.30; P = .79) or without insurance (AOR, 0.85; 95% CI, 0.47-1.54; P = .60) did not increase more than for patients with commercial insurance in hospitals with a high COVID-19 burden compared with hospitals with a low COVID-19 burden. These findings were similar in hospitals with very high COVID-19 burdens. CONCLUSIONS AND RELEVANCE In this cross-sectional study, the first wave of the COVID-19 pandemic was associated with a higher risk of mortality after surgery in hospitals with more than 25.0% of patients with COVID-19. However, the pandemic was not associated with greater increases in mortality among patients with no insurance or patients with Medicaid compared with patients with commercial insurance in hospitals with a very high COVID-19 burden.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| | | | - Ernie Shippey
- Vizient Center for Advanced Analytics, Chicago, Illinois
| | | | | | - Patricia W. Stone
- Center for Health Policy, Columbia School of Nursing, New York, New York
| | - Jingjing Shang
- Center for Health Policy, Columbia School of Nursing, New York, New York
| | - Stewart J. Lustik
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Heather L. Lander
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Igor Gosev
- Department of Surgery, University of Rochester School of Medicine, Rochester, New York
| | - Karen E. Joynt Maddox
- Department of Medicine, Washington University in St Louis, Missouri
- Center for Health Economics and Policy at the Institute for Public Health, Washington University in St Louis, Missouri
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13
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Glance LG, Benesch CG, Holloway RG, Thirukumaran CP, Nadler JW, Eaton MP, Fleming FJ, Dick AW. Association of Time Elapsed Since Ischemic Stroke With Risk of Recurrent Stroke in Older Patients Undergoing Elective Nonneurologic, Noncardiac Surgery. JAMA Surg 2022; 157:e222236. [PMID: 35767247 DOI: 10.1001/jamasurg.2022.2236] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Perioperative strokes are a major cause of death and disability. There is limited information on which to base decisions for how long to delay elective nonneurologic, noncardiac surgery in patients with a history of stroke. Objective To examine whether an association exists between the time elapsed since an ischemic stroke and the risk of recurrent stroke in older patients undergoing elective nonneurologic, noncardiac surgery. Design, Setting, and Participants This cohort study used data from the 100% Medicare Provider Analysis and Review files, including the Master Beneficiary Summary File, between 2011 and 2018 and included elective nonneurologic, noncardiac surgeries in patients 66 years or older. Patients were excluded if they had more than 1 procedure during a 30-day period, were transferred from another hospital or facility, were missing information on race and ethnicity, were admitted in December 2018, or had tracheostomies or gastrostomies. Data were analyzed May 7 to October 23, 2021. Exposures Time interval between a previous hospital admission for acute ischemic stroke and surgery. Main Outcomes and Measures Acute ischemic stroke during the index surgical admission or rehospitalization for stroke within 30 days of surgery, 30-day all-cause mortality, composite of stroke and mortality, and discharge to a nursing home or skilled nursing facility. Multivariable logistic regression models were used to estimate adjusted odds ratios (AORs) to quantify the association between outcome and time since ischemic stroke. Results The final cohort included 5 841 539 patients who underwent elective nonneurologic, noncardiac surgeries (mean [SD] age, 74.1 [6.1] years; 3 371 329 [57.7%] women), of which 54 033 (0.9%) had a previous stroke. Patients with a stroke within 30 days before surgery had higher adjusted odds of perioperative stroke (AOR, 8.02; 95% CI, 6.37-10.10; P < .001) compared with patients without a previous stroke. The adjusted odds of stroke were not significantly different at an interval of 61 to 90 days between previous stroke and surgery (AOR, 5.01; 95% CI, 4.00-6.29; P < .001) compared with 181 to 360 days (AOR, 4.76; 95% CI, 4.26-5.32; P < .001). The adjusted odds of 30-day all-cause mortality were higher in patients who underwent surgery within 30 days of a previous stroke (AOR, 2.51; 95% CI, 1.99-3.16; P < .001) compared with those without a history of stroke, and the AOR decreased to 1.49 (95% CI, 1.15-1.92; P < .001) at 61 to 90 days from previous stroke to surgery but did not decline significantly, even after an interval of 360 or more days. Conclusions and Relevance The findings of this cohort study suggest that, among patients undergoing nonneurologic, noncardiac surgery, the risk of stroke and death leveled off when more than 90 days elapsed between a previous stroke and elective surgery. These findings suggest that the recent scientific statement by the American Heart Association to delay elective nonneurologic, noncardiac surgery for at least 6 months after a recent stroke may be too conservative.
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Affiliation(s)
- Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York.,Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York.,RAND Health, RAND, Boston, Massachusetts.,Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York
| | - Curtis G Benesch
- Department of Neurology, University of Rochester School of Medicine, Rochester, New York
| | - Robert G Holloway
- Department of Neurology, University of Rochester School of Medicine, Rochester, New York
| | - Caroline P Thirukumaran
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York.,Department of Orthopedics, University of Rochester School of Medicine, Rochester, New York
| | - Jacob W Nadler
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Michael P Eaton
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Fergal J Fleming
- Department of Surgery, University of Rochester School of Medicine, Rochester, New York
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14
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Glance LG, Chandrasekar EK, Shippey E, Stone PW, Dutton R, McCormick PJ, Shang J, Lustik SJ, Wu IY, Eaton MP, Dick AW. Association Between the COVID-19 Pandemic and Disparities in Access to Major Surgery in the US. JAMA Netw Open 2022; 5:e2213527. [PMID: 35604684 PMCID: PMC9127559 DOI: 10.1001/jamanetworkopen.2022.13527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Racial minority groups account for 70% of excess deaths not related to COVID-19. Understanding the association of the Centers for Medicare & Medicaid Services' (CMS's) moratorium delaying nonessential operations with racial disparities will help shape future pandemic responses. OBJECTIVE To evaluate the association of the CMS's moratorium on elective operations during the first wave of the COVID-19 pandemic among Black individuals, Asian individuals, and individuals of other races compared with White individuals. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study assessed a 719-hospital retrospective cohort of 3 470 905 adult inpatient hospitalizations for major surgery between January 1, 2018, and October 31, 2020. EXPOSURE The first wave of COVID-19 infections between March 1, 2020, and May 31, 2020. MAIN OUTCOMES AND MEASURES The main outcome was the association between changes in monthly elective surgical case volumes and the first wave of COVID-19 infections as a function of patient race, evaluated using negative binomial regression analysis. RESULTS Among 3 470 905 adults (1 823 816 female [52.5%]) with inpatient hospitalizations for major surgery, 70 752 (2.0%) were Asian, 453 428 (13.1%) were Black, 2 696 929 (77.7%) were White, and 249 796 (7.2%) were individuals of other races. The number of monthly elective cases during the first wave was 49% (incident rate ratio [IRR], 0.49; 95% CI, 0.486-0.492; P < .001) compared with the baseline period. The relative reduction in unadjusted elective surgery cases for Black (unadjusted IRR, 0.99; 95% CI, 0.97-1.01; P = .36), Asian (unadjusted IRR, 1.08; 95% CI, 1.03-1.14; P = .001), and other race individuals (unadjusted IRR, 0.97; 95% CI, 0.95-1.00; P = .05) during the surge period compared with the baseline period was very close to the change in cases for White individuals. After adjustment for age, sex, comorbidities, and surgical procedure, there was still no evidence that the first wave of the pandemic was associated with disparities in access to elective surgery. CONCLUSIONS AND RELEVANCE In this cross-sectional study, the CMS's moratorium on nonessential operations was associated with a 51% reduction in elective operations. It was not associated with greater reductions in operations for racial minority individuals than for White individuals. This evidence suggests that the early response to the pandemic did not increase disparities in access to surgical care.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| | - Eeshwar K. Chandrasekar
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Ernie Shippey
- Vizient Center for Advanced Analytics, Chicago, Illinois
| | - Patricia W. Stone
- Columbia School of Nursing, Center for Health Policy, New York, New York
| | | | | | - Jingjing Shang
- Columbia School of Nursing, Center for Health Policy, New York, New York
| | - Stewart J. Lustik
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Isaac Y. Wu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Michael P. Eaton
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
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15
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Thirukumaran CP, Ricciardi BF, Cai X, Holloway RG, Li Y, Glance LG. Association of Medicare Mandatory Bundled Payment Reform With Joint Replacement Surgery Use for Beneficiaries With Alzheimer Disease and Related Dementias. JAMA Health Forum 2022; 3:e215111. [PMID: 35977279 PMCID: PMC8903111 DOI: 10.1001/jamahealthforum.2021.5111] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/15/2021] [Indexed: 11/18/2022] Open
Abstract
Question Is the Comprehensive Care for Joint Replacement (CJR) model associated with changes in hip and knee replacement use for Medicare beneficiaries with Alzheimer disease and related dementias (ADRD)? Findings In this cohort study of 24 598 729 beneficiary-year observations among 9 624 461 unique beneficiaries, CJR was statistically significantly associated with a decrease in hip replacement use for beneficiaries with and without ADRD; however, the gap in use between these groups did not change with CJR implementation. The CJR model was not associated with changes in knee replacement use. Meaning This study found that the CJR model was not associated with a disproportionate reduction in joint replacement use for Medicare beneficiaries with ADRD. Importance Medicare beneficiaries with Alzheimer disease and related dementias (ADRD) are a particularly vulnerable group in whom arthritis is a frequently occurring comorbidity. Medicare’s mandatory bundled payment reform—the Comprehensive Care for Joint Replacement (CJR) model—was intended to improve quality and reduce spending in beneficiaries undergoing joint replacement surgical procedures for arthritis. In the absence of adjustment for clinical risk, hospitals may avoid performing elective joint replacements for beneficiaries with ADRD. Objective To evaluate the association of the CJR model with utilization of joint replacements for Medicare beneficiaries with ADRD. Design, Setting, and Participants This cohort study used national Medicare data from 2013 to 2017 and multivariable linear probability models and a triple differences estimation approach. Medicare beneficiaries with a diagnosis of arthritis were identified from 67 metropolitan statistical areas (MSAs) mandated to participate in CJR and 104 control MSAs. Data were analyzed from July 2020 to July 2021. Exposures Implementation of the CJR model in 2016. Main Outcomes and Measures Outcomes were separate binary indicators for whether or not a beneficiary underwent hip or knee replacement. Key independent variables were the MSA group, before-CJR and after-CJR phase, ADRD diagnosis, and their interactions. The linear probability models controlled for beneficiary characteristics, MSA fixed effects, and time trends. Results The study included 24 598 729 beneficiary-year observations for 9 624 461 unique beneficiaries, of which 250 168 beneficiaries underwent hip and 474 751 underwent knee replacements. The mean (SD) age of the 2013 cohort was 77.1 (7.9) years, 3 110 922 (66.4%) were women, 3 928 432 (83.8%) were non-Hispanic White, 792 707 (16.9%) were dually eligible for Medicaid, and 885 432 (18.9%) had an ADRD diagnosis. Before CJR implementation, joint replacement rates were lower among beneficiaries with ADRD (hip replacements: 0.38% vs 1.17% for beneficiaries with and without ADRD, respectively; P < .001; knee replacements: 0.70% vs 2.25%; P < .001). After controlling for relevant covariates, CJR was associated with a 0.07-percentage-point decline in hip replacements for beneficiaries with ADRD (95% CI, −0.13 to −0.001; P = .046) and a 0.07-percentage-point decline for beneficiaries without ADRD (95% CI, −0.12 to −0.02; P = .01) residing in CJR MSAs compared with beneficiaries in control MSAs. However, this change in hip replacement rates for beneficiaries with ADRD was not statistically significantly different from the change for beneficiaries without ADRD (percentage point difference: 0.01; 95% CI, −0.08 to 0.09; P = .88). No statistically significant changes in knee replacement rates were noted for beneficiaries with ADRD compared with those without ADRD with CJR implementation (percentage point difference: −0.03, 95% CI, −0.09 to 0.02; P = .27). Conclusions and Relevance In this cohort study of Medicare beneficiaries with arthritis, the CJR model was not associated with a decline in joint replacement utilization among beneficiaries with ADRD compared with beneficiaries without ADRD in the first 2 years of the program, thereby alleviating patient selection concerns.
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Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics, University of Rochester, New York
- Department of Public Health Sciences, University of Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, New York
| | - Benjamin F. Ricciardi
- Department of Orthopaedics, University of Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, New York
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, New York
| | - Robert G. Holloway
- Department of Neurology, University of Rochester, New York
- Department of Medicine, University of Rochester, New York
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, New York
| | - Laurent G. Glance
- Department of Public Health Sciences, University of Rochester, New York
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
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16
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Glance LG, Dick AW, Wu I. Safety of Complete Anesthesia Handovers in the Cardiac Surgical Patient. JAMA Netw Open 2022; 5:e2148169. [PMID: 35147690 DOI: 10.1001/jamanetworkopen.2021.48169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| | | | - Isaac Wu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
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17
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Glance LG, Nerenz DR, Joynt Maddox KE, Hall BL, Dick AW. Reproducibility of Hospital Rankings Based on Centers for Medicare & Medicaid Services Hospital Compare Measures as a Function of Measure Reliability. JAMA Netw Open 2021; 4:e2137647. [PMID: 34874402 PMCID: PMC8652605 DOI: 10.1001/jamanetworkopen.2021.37647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Unreliable performance measures can mask poor-quality care and distort financial incentives in value-based purchasing. OBJECTIVE To examine the association between test-retest reliability and the reproducibility of hospital rankings. DESIGN, SETTING, AND PARTICIPANTS In a cross-sectional design, Centers for Medicare & Medicaid Services Hospital Compare data were analyzed for the 2017 (based on 2014-2017 data) and 2018 (based on 2015-2018 data) reporting periods. The study was conducted from December 13, 2020, to September 30, 2021. This analysis was based on 28 measures, including mortality (acute myocardial infarction, congestive heart failure, pneumonia, and coronary artery bypass grafting), readmissions (acute myocardial infarction, congestive heart failure, pneumonia, and coronary artery bypass grafting), and surgical complications (postoperative acute kidney failure, postoperative respiratory failure, postoperative sepsis, and failure to rescue). EXPOSURES Measure reliability based on test-retest reliability testing. MAIN OUTCOMES AND MEASURES The reproducibility of hospital rankings was quantified by calculating the reclassification rate across the 2017 and 2018 reporting periods after categorizing the hospitals into terciles, quartiles, deciles, and statistical outliers. Linear regression analysis was used to examine the association between the reclassification rate and the intraclass correlation coefficient for each of the classification systems. RESULTS The analytic cohort consisted of 28 measures from 4452 hospitals with a median of 2927 (IQR, 2378-3160) hospitals contributing data for each measure. The hospitals participating in the Inpatient Prospective Payment System (n = 3195) had a median bed size of 141 (IQR, 69-261), average daily census of 70 (IQR, 24-155) patients, and a median disproportionate share hospital percentage of 38.2% (IQR, 18.7%-36.6%). The median intraclass correlation coefficient was 0.78 (IQR, 0.72-0.81), ranging between 0.50 and 0.85. The median reclassification rate was 70% (IQR, 62%-71%) when hospitals were ranked by deciles, 43% (IQR, 39%-45%) when ranked by quartiles, 34% (IQR, 31%-36%) when ranked by terciles, and 3.8% (IQR, 2.0%-6.2%) when ranked by outlier status. Increases in measure reliability were not associated with decreases in the reclassification rate. Each 0.1-point increase in the intraclass correlation coefficient was associated with a 6.80 (95% CI, 2.28-11.30; P = .005) percentage-point increase in the reclassification rate when hospitals were ranked into performance deciles, 4.15 (95% CI, 1.16-7.14; P = .008) when ranked into performance quartiles, 1.47 (95% CI, 1.84, 4.77; P = .37) when ranked into performance terciles, and 3.70 (95% CI, 1.30-6.09; P = .004) when ranked by outlier status. CONCLUSIONS AND RELEVANCE In this study, more reliable measures were not associated with lower rates of reclassifying hospitals using test-retest reliability testing. These findings suggest that measure reliability should not be assessed with test-retest reliability testing.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| | - David R. Nerenz
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan
| | - Karen E. Joynt Maddox
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Center for Health Economics and Policy at the Institute for Public Health, Washington University in St Louis, St Louis, Missouri
| | - Bruce L. Hall
- Department of Surgery, Washington University in St Louis, St Louis, Missouri
- Olin Business School, Washington University in St Louis, St Louis, Missouri
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
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Nicoara A, Song P, Bollen BA, Paone G, Abernathy JJ, Taylor MA, Habib RH, Del Rio JM, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2021 Update on Echocardiography. Ann Thorac Surg 2021; 113:13-24. [PMID: 34536378 DOI: 10.1016/j.athoracsur.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/05/2021] [Accepted: 09/07/2021] [Indexed: 11/01/2022]
Abstract
The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) is the world's premier clinical outcomes registry for adult cardiac surgery and a driving force for quality improvement in cardiac surgery. Echocardiographic data provide a wealth of hemodynamic, structural, and functional data and have been part of STS ACSD data collection since its inception. An increasing body of evidence suggests that the use of echocardiography in patients undergoing cardiac surgery has a positive impact on postoperative outcomes. In this report, we describe and summarize the type and rate of reporting of echocardiography-related variables in the STS ACSD, including the Adult Cardiac Anesthesiology Module, from July 2017 to December 2019 for the most frequently performed cardiac surgical procedures. With this review, we aim to increase awareness of the importance of collecting accurate and consistent echocardiography data in the STS ACSD and to highlight opportunities for growth and improvement.
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Affiliation(s)
- Alina Nicoara
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Pinping Song
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Gaetano Paone
- Department of Surgery, Emory University, Atlanta, Georgia
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute/Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | | | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Lincoln, Nebraska
| | - G Burkhard Mackensen
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Department of Anesthesiology Vanderbilt University, Nashville, Tennessee.
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19
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Glance LG, Thirukumaran CP, Feng C, Lustik SJ, Dick AW. Association Between the Physician Quality Score in the Merit-Based Incentive Payment System and Hospital Performance in Hospital Compare in the First Year of the Program. JAMA Netw Open 2021; 4:e2118449. [PMID: 34342653 PMCID: PMC8335582 DOI: 10.1001/jamanetworkopen.2021.18449] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The scientific validity of the Merit-Based Incentive Payment System (MIPS) quality score as a measure of hospital-level patient outcomes is unknown. OBJECTIVE To examine whether better physician performance on the MIPS quality score is associated with better hospital outcomes. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of 38 830 physicians used data from the Centers for Medicare & Medicaid Services (CMS) Physician Compare (2017) merged with CMS Hospital Compare data. Data analysis was conducted from September to November 2020. MAIN OUTCOMES AND MEASURES Linear regression was used to examine the association between physician MIPS quality scores aggregated at the hospital level and hospitalwide measures of (1) postoperative complications, (2) failure to rescue, (3) individual postoperative complications, and (4) readmissions. RESULTS The study cohort of 38 830 clinicians (5198 [14.6%] women; 12 103 [31.6%] with 11-20 years in practice) included 6580 (17.2%) general surgeons, 8978 (23.4%) orthopedic surgeons, 1617 (4.2%) vascular surgeons, 582 (1.5%) cardiac surgeons, 904 (2.4%) thoracic surgeons, 18 149 (47.4%) anesthesiologists, and 1520 (4.0%) intensivists at 3055 hospitals. The MIPS quality score was not associated with the hospital composite rate of postoperative complications. MIPS quality scores for vascular surgeons in the 11th to 25th percentile, compared with those in the 51st to 100th percentile, were associated with a 0.55-percentage point higher hospital rate of failure to rescue (95% CI, 0.06-1.04 percentage points; P = .03). MIPS quality scores for cardiac surgeons in the 1st to 10th percentile, compared with those in the 51st to 100th percentile, were associated with a 0.41-percentage point higher hospital coronary artery bypass graft (CABG) mortality rate (95% CI, 0.10-0.71 percentage points; P = .01). MIPS quality scores for cardiac surgeons in the 1st to 10th percentile and 11th to 25th percentile, compared with those in the 51st to 100th percentile, were associated with 0.65-percentage point (95% CI, 0.013-1.16 percentage points; P = .02) and 0.48-percentage point (95% CI, 0.07-0.90 percentage points; P = .02) higher hospital CABG readmission rates, respectively. CONCLUSIONS AND RELEVANCE In this study, better performance on the physician MIPS quality score was associated with better hospital surgical outcomes for some physician specialties during the first year of MIPS.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| | | | - Changyong Feng
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine, Rochester, New York
| | - Stewart J. Lustik
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
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20
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Nerenz DR, Austin JM, Deutscher D, Maddox KEJ, Nuccio EJ, Teigland C, Weinhandl E, Glance LG. Adjusting Quality Measures For Social Risk Factors Can Promote Equity In Health Care. Health Aff (Millwood) 2021; 40:637-644. [PMID: 33819097 DOI: 10.1377/hlthaff.2020.01764] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Risk adjustment of quality measures using clinical risk factors is widely accepted; risk adjustment using social risk factors remains controversial. We argue here that social risk adjustment is appropriate and necessary in defined circumstances and that social risk adjustment should be the default option when there are valid empirical arguments for and against adjustment for a given measure. Social risk adjustment is an important way to avoid exacerbating inequity in the health care system.
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Affiliation(s)
- David R Nerenz
- David R. Nerenz is the director emeritus of the Center for Health Policy and Health Services Research, Henry Ford Health System, in Detroit, Michigan
| | - J Matthew Austin
- J. Matthew Austin is an assistant professor at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, in Baltimore, Maryland
| | - Daniel Deutscher
- Daniel Deutscher is a senior research scientist at Net Health Systems, Inc., in Pittsburgh, Pennsylvania, and the director of patient reported outcome measures at the MaccabiTech Institute for Research and Innovation, Maccabi Healthcare Services, in Tel Aviv, Israel
| | - Karen E Joynt Maddox
- Karen E. Joynt Maddox is an assistant professor of medicine in the Department of Internal Medicine, Washington University School of Medicine, in St. Louis, Missouri
| | - Eugene J Nuccio
- Eugene J. Nuccio is an assistant professor of medicine at the University of Colorado, Anschutz Medical Campus, in Denver, Colorado
| | - Christie Teigland
- Christie Teigland is a principal in the health economics and advanced analytics practice at Avalere Health, in Washington, D.C
| | - Eric Weinhandl
- Eric Weinhandl is a senior epidemiologist in the Chronic Disease Research Group at the Hennepin Healthcare Research Institute, in Minneapolis, Minnesota
| | - Laurent G Glance
- Laurent G. Glance is vice chair for research and a professor in the Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, in Rochester, New York
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21
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Abstract
BACKGROUND Understanding the current burden of coronavirus disease 2019 (COVID-19) deaths in vulnerable populations will help inform efforts by policymakers to address disparities in COVID-19 outcomes. OBJECTIVE The objective of this study was to examine the association between COVID-19 deaths and the county-level proportions of non-Hispanic Black and Hispanic residents. RESEARCH DESIGN AND METHODS A retrospective study using COVID-19 mortality data from USA Facts linked to data from the US Census Bureau, the Health Resources & Services Administration Area Health Resources file, and the US Census Bureau. Negative binomial regression was used to estimate the association between the total county COVID-19 deaths during consecutive 30-day intervals and the proportion of non-Hispanic Blacks and Hispanic residents after adjusting for resident demographics, comorbidity burden, rurality, social determinants of health, and health care resources. RESULTS In April, counties (n=179) with >40% Blacks had 6-fold higher death rates than counties (n=1521) with <2% Blacks [incident rate ratio (IRR)=6.58, 95% confidence interval (CI): 3.29-13.2, P<0.001]. These counties had higher death rates until October, but were no different than referent counties in November. In April, death rates in counties with >40% Hispanic residents were similar to death rates in counties with <2% Hispanic residents. Death rates in these counties peaked in August (IRR=3.14, 95% CI: 1.69-5.82, P<0.001) but were also no different than referent counties in November. These effects were robust after adjusting for county-level characteristics. Before August, death rates differed little by insurance status, but since then, counties with >15% uninsurance rates had up to 2-fold higher mortality rates (IRR=1.97, 95% CI: 1.19-3.27, P<0.001) than counties with <5% uninsurance rates. CONCLUSION Counties with high concentrations of non-Hispanic Blacks were disproportionately affected by COVID-19 throughout most of the pandemic, but other social determinants of health such as health insurance are now playing a more prominent role than race and ethnicity.
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Affiliation(s)
- Laurent G. Glance
- Departments of Anesthesiology and Perioperative Medicine
- Public Health Sciences, University of Rochester School of Medicine, Rochester, NY
- RAND Health, RAND, Boston, MA
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22
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Thirukumaran CP, Kim Y, Cai X, Ricciardi BF, Li Y, Fiscella KA, Mesfin A, Glance LG. Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement. JAMA Netw Open 2021; 4:e2111858. [PMID: 34047790 PMCID: PMC8164097 DOI: 10.1001/jamanetworkopen.2021.11858] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. OBJECTIVE To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. DESIGN, SETTING, AND PARTICIPANTS This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. EXPOSURES Implementation of the CJR model in 2016. MAIN OUTCOMES AND MEASURES Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. RESULTS The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. CONCLUSIONS AND RELEVANCE Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.
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MESH Headings
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/standards
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/standards
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Cohort Studies
- Elective Surgical Procedures/economics
- Elective Surgical Procedures/standards
- Elective Surgical Procedures/statistics & numerical data
- Eligibility Determination/standards
- Eligibility Determination/statistics & numerical data
- Female
- Healthcare Disparities/economics
- Healthcare Disparities/standards
- Healthcare Disparities/statistics & numerical data
- Humans
- Male
- Medicare/economics
- Medicare/standards
- Medicare/statistics & numerical data
- Race Factors
- Reimbursement Mechanisms
- Socioeconomic Factors
- United States
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Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Yeunkyung Kim
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Benjamin F. Ricciardi
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Kevin A. Fiscella
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Department of Family Medicine, University of Rochester, Rochester, New York
- Center for Community Health and Prevention, University of Rochester, Rochester, New York
| | - Addisu Mesfin
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Laurent G. Glance
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
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23
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Benesch C, Glance LG, Derdeyn CP, Fleisher LA, Holloway RG, Messé SR, Mijalski C, Nelson MT, Power M, Welch BG. Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association. Circulation 2021; 143:e923-e946. [PMID: 33827230 DOI: 10.1161/cir.0000000000000968] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.
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24
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Glance LG, Thirukumaran CP, Shippey E, Lustik SJ, Dick AW. Impact of medicaid expansion on disparities in revascularization in patients hospitalized with acute myocardial infarction. PLoS One 2020; 15:e0243385. [PMID: 33362198 PMCID: PMC7757880 DOI: 10.1371/journal.pone.0243385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/20/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Blacks are more likely to live in poverty and be uninsured, and are less likely to undergo revascularization after am acute myocardial infarction compared to whites. The objective of this study was to determine whether Medicaid expansion was associated with a reduction in revascularization disparities in patients admitted with an acute myocardial infarction. METHODS Retrospective analysis study using data (2010-2018) from hospitals participating in the University Health Systems Consortium, now renamed the Vizient Clinical Database. Comparative interrupted time series analysis was used to compare changes in the use of revascularization therapies (PCI and CABG) in white versus non-Hispanic black patients hospitalized with either ST-segment elevation (STEMI) or non-ST-segment elevation acute myocardial infarctions (NSTEMI) after Medicaid expansion. RESULTS The analytic cohort included 68,610 STEMI and 127,378 NSTEMI patients. The percentage point decrease in the uninsured rate for STEMIs and NSTEMIs was greater for blacks in expansion states compared to whites in expansion states. For patients with STEMIs, differences in black versus white revascularization rates decreased by 2.09 percentage points per year (95% CI, 0.29-3.88, P = 0.023) in expansion versus non-expansion states after adjusting for patient and hospital characteristics. Black patients hospitalized with STEMI in non-expansion states experienced a 7.24 percentage point increase in revascularization rate in 2014 (95% CI, 2.83-11.7, P < 0.001) but did not experience significant annual percentage point increases in the rate of revascularization in subsequent years (1.52; 95% CI, -0.51-3.55, P = 0.14) compared to whites in non-expansion states. Medicaid expansion was not associated with changes in the revascularization rate for either blacks or whites hospitalized with NSTEMIs. CONCLUSION Medicaid expansion was associated with greater reductions in the number of uninsured blacks compared to uninsured whites. Medicaid expansion was not associated, however, with a reduction in revascularization disparities between black and white patients admitted with acute myocardial infarctions.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY, United States of America
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, NY, United States of America
- RAND Health, RAND, Boston, MA, United States of America
| | - Caroline P. Thirukumaran
- Department of Orthopedics, University of Rochester School of Medicine, Rochester, NY, United States of America
| | - Ernie Shippey
- Research Analyst, Vizient, Irving, TX, United States of America
| | - Stewart J. Lustik
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY, United States of America
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25
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Thirukumaran CP, Cai X, Glance LG, Kim Y, Ricciardi BF, Fiscella KA, Li Y. Geographic Variation and Disparities in Total Joint Replacement Use for Medicare Beneficiaries: 2009 to 2017. J Bone Joint Surg Am 2020; 102:2120-2128. [PMID: 33079898 PMCID: PMC8190867 DOI: 10.2106/jbjs.20.00246] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little is known about how the geographic variation and disparities in use of elective primary total hip and knee replacements for Medicare beneficiaries have evolved in recent years. The study objectives are to determine these variations and disparities, whether Black Medicare beneficiaries have continued to undergo fewer total hip replacements and total knee replacements across regions, and whether disparities affected all Black beneficiaries or mainly affected socioeconomically disadvantaged Black beneficiaries. METHODS We used 2009 to 2017 Medicare enrollment and claims data to examine Hospital Referral Region (HRR)-level variation and disparities by race (non-Hispanic White and Black) and socioeconomic status (Medicare-only and dual eligibility for both Medicare and Medicaid). The outcomes were HRR-level age and sex-standardized total hip replacement and total knee replacement utilization rates for White Medicare-only beneficiaries, White dual-eligible beneficiaries, Black Medicare-only beneficiaries, and Black dual-eligible beneficiaries, and the differences in rates between these groups as a representation of disparities. The key exposure variables were race-socioeconomic group and year. We constructed multilevel mixed-effects linear regression models to estimate trends in total hip replacement and total knee replacement rates and to examine whether rates were lower in HRRs with high percentages of Black beneficiaries or dual-eligible beneficiaries. RESULTS The study included 924,844 total hip replacements and 2,075,968 total knee replacements. In 2017, the mean HRR-level total hip replacement rate was 4.64 surgical procedures per 1,000 beneficiaries, and the mean HRR-level total knee replacement rate was 9.66 surgical procedures per 1,000 beneficiaries, with a threefold variation across HRRs. In 2017, the total hip replacement rate was 32% higher for White Medicare-only beneficiaries and 48% higher for Black Medicare-only beneficiaries than in 2009 (p < 0.001). However, because the surgical rates for White and Black dual-eligible beneficiaries remained unchanged over the study period, the 2017 Medicare-only and dual-eligible disparity for White beneficiaries increased by 0.75 surgical procedures per 1,000 from 2009 (40.98% increase; p = 0.03), and the disparity for Black beneficiaries by 1.13 surgical procedures per 1,000 beneficiaries (297.37% increase; p < 0.001). The total knee replacement disparities remained unchanged. Notably, the rates for White dual-eligible beneficiaries were significantly lower than those for Black Medicare-only beneficiaries (p < 0.001 for both total hip replacements and total knee replacements), and fewer surgical procedures were conducted in HRRs with a higher density of Black or dual-eligible beneficiaries. CONCLUSIONS Although the total hip replacement use for Medicare-only beneficiaries of both races increased, disparities for White and Black dual-eligible beneficiaries (compared with their Medicare-only counterparts) are increasing. Efforts to improve equity must identify and address both racial and socioeconomic barriers and focus on regions with high concentrations of disadvantaged beneficiaries. CLINICAL RELEVANCE Although total hip replacements and total knee replacements are highly successful surgical procedures for end-stage osteoarthritis, our findings show that, as recently as 2017, Black beneficiaries and those dual eligible for Medicaid (a proxy for socioeconomic status) are less likely to undergo these surgical procedures and that there is profound geographic variation in the use of these surgical procedures. This evidence is essential for the design and implementation of disparity-reduction strategies focused on patients, providers, and geographic areas that can potentially improve the equity in joint replacement care.
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Affiliation(s)
- Caroline P. Thirukumaran
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York,Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Xueya Cai
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York
| | - Laurent G. Glance
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York
| | - Yeunkyung Kim
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York
| | - Benjamin F. Ricciardi
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York,Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Kevin A. Fiscella
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York,Center for Community Health and Prevention, University of Rochester, Rochester, New York
| | - Yue Li
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York
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26
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Del Rio JM, Abernathy JJ, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. Anesth Analg 2020; 131:1383-1396. [PMID: 33079860 DOI: 10.1213/ane.0000000000005093] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- J Mauricio Del Rio
- From the Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Del Rio JM, Jake Abernathy J, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. J Cardiothorac Vasc Anesth 2020; 35:22-34. [PMID: 33008722 DOI: 10.1053/j.jvca.2020.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The Society of Cardiovascular Anesthesiologists, in partnership with The Society of Thoracic Surgeons, has developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database. The goal of this landmark collaboration is to advance clinical care, quality, and knowledge, and to demonstrate the value of cardiac anesthesiology in the perioperative care of cardiac surgical patients. Participation in the Adult Cardiac Anesthesiology Section has been optional since its inception in 2014 but has progressively increased. Opportunities for further growth and improvement remain. In this first update report on quality and outcomes of the Adult Cardiac Anesthesiology Section, we present an overview of the clinically significant anesthesia and surgical variables submitted between 2015 and 2018. Our review provides a summary of quality measures and outcomes related to the current practice of cardiothoracic anesthesiology. We also emphasize the potential for addressing high-impact research questions as data accumulate, with the overall goal of elucidating the influence of cardiac anesthesiology contributions to patient outcomes within the framework of the cardiac surgical team.
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Affiliation(s)
- J Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
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Del Rio JM, Abernathy JJ, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. Ann Thorac Surg 2020; 110:1447-1460. [PMID: 33008569 DOI: 10.1016/j.athoracsur.2020.05.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 10/23/2022]
Abstract
The Society of Cardiovascular Anesthesiologists, in partnership with The Society of Thoracic Surgeons, has developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database. The goal of this landmark collaboration is to advance clinical care, quality, and knowledge, and to demonstrate the value of cardiac anesthesiology in the perioperative care of cardiac surgical patients. Participation in the Adult Cardiac Anesthesiology Section has been optional since its inception in 2014 but has progressively increased. Opportunities for further growth and improvement remain. In this first update report on quality and outcomes of the Adult Cardiac Anesthesiology Section, we present an overview of the clinically significant anesthesia and surgical variables submitted between 2015 and 2018. Our review provides a summary of quality measures and outcomes related to the current practice of cardiothoracic anesthesiology. We also emphasize the potential for addressing high-impact research questions as data accumulate, with the overall goal of elucidating the influence of cardiac anesthesiology contributions to patient outcomes within the framework of the cardiac surgical team.
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Affiliation(s)
- J Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
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Thirukumaran CP, Glance LG, Cai X, Balkissoon R, Mesfin A, Li Y. Performance Of Safety-Net Hospitals In Year 1 Of The Comprehensive Care For Joint Replacement Model. Health Aff (Millwood) 2020; 38:190-196. [PMID: 30715982 PMCID: PMC6446900 DOI: 10.1377/hlthaff.2018.05264] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Comprehensive Care for Joint Replacement (CJR) model of 2016 aims to improve the quality and costs of care for Medicare beneficiaries undergoing hip and knee replacements. However, there are concerns that the safety-net hospitals that care for the greatest number of vulnerable patients may perform poorly in CJR. In this study, we used Medicare’s CJR data to evaluate the performance of 792 hospitals mandated to participate in the first year of CJR. We found that in comparison to non-safety-net hospitals, 42 percent fewer safety-net hospitals qualified for rewards based on their quality and spending performance (33 percent of safety-net hospitals qualified, compared to 57 percent of non-safety-net hospitals), and safety-net hospitals’ rewards per episode were 39 percent smaller ($456 compared to $743). Continuation of this performance trend might place safety-net hospitals at increased risk of penalties in future years. Medicare and hospital strategies such as those that reward high-quality care for vulnerable patients might enable safety-net hospitals to compete effectively in CJR.
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Affiliation(s)
- Caroline P Thirukumaran
- Caroline P. Thirukumaran ( ) is an assistant professor in the Department of Orthopaedics and Department of Public Health Sciences, University of Rochester, in New York
| | - Laurent G Glance
- Laurent G. Glance is vice chair for research and a professor in the Department of Anesthesiology and Department of Public Health Sciences, University of Rochester
| | - Xueya Cai
- Xueya Cai is a research associate professor in the Department of Biostatistics and Computational Biology, University of Rochester
| | - Rishi Balkissoon
- Rishi Balkissoon is an assistant professor in the Department of Orthopaedics, University of Rochester
| | - Addisu Mesfin
- Addisu Mesfin is an associate professor in the Department of Orthopaedics, University of Rochester
| | - Yue Li
- Yue Li is a professor in the Department of Public Health Sciences, University of Rochester
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Kim Y, Glance LG, Holloway RG, Li Y. Medicare Shared Savings Program and readmission rate among patients with ischemic stroke. Neurology 2020; 95:e1071-e1079. [PMID: 32554774 DOI: 10.1212/wnl.0000000000010080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/27/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Hospitals participating in the Medicare Shared Savings Program (MSSP) share with the Centers for Medicare and Medicaid Services (CMS) the savings generated by reduced cost of care. Our aim was to determine whether MSSP is associated with changes in readmissions and mortality for Medicare patients hospitalized with ischemic stroke, and whether MSSP has a different impact on safety net hospitals (SNHs) compared to non-SNHs. METHODS This study was based on the CMS Hospital Compare data for risk-standardized 30-day readmission and mortality rates for Medicare patients hospitalized with ischemic strokes between 2010 and 2017. With a propensity score-matched sample, hospital-level difference-in-difference analysis was used to determine whether MSSP was associated with changes in hospital readmission and mortality as well as to examine the impact of MSSP on SNHs compared to non-SNHs. RESULTS MSSP-participating hospitals had slightly greater reductions in readmission rates compared to matched nonparticipating hospitals (difference, 0.25 percentage points; 95% confidence interval [CI], -0.42 to -0.08). Mortality rates decreased among all hospitals, but mortality reduction was not significantly different between MSSP-participating hospitals and matched hospitals (difference, 0.06 percentage points; 95% CI, -0.28 to 0.17). Prior to MSSP, readmission rates in SNHs were higher compared to non-SNHs, but MSSP did not have significantly different impact on hospital readmission and mortality rates for SNHs and non-SNHs. CONCLUSION MSSP led to slightly fewer readmissions without increases in mortality for Medicare patients hospitalized with ischemic stroke. Similar reductions in readmission rates were observed in SNHs and non-SNHs participating in MSSP, indicating persistent gaps between SNHs and non-SNHs.
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Affiliation(s)
- Yeunkyung Kim
- From the Department of Public Health Sciences, Division of Health Policy and Outcomes Research (Y.K., L.G.G., Y.L.), Department of Anesthesiology (L.G.G.), and Department of Neurology (R.G.H.), University of Rochester Medical Center, NY.
| | - Laurent G Glance
- From the Department of Public Health Sciences, Division of Health Policy and Outcomes Research (Y.K., L.G.G., Y.L.), Department of Anesthesiology (L.G.G.), and Department of Neurology (R.G.H.), University of Rochester Medical Center, NY
| | - Robert G Holloway
- From the Department of Public Health Sciences, Division of Health Policy and Outcomes Research (Y.K., L.G.G., Y.L.), Department of Anesthesiology (L.G.G.), and Department of Neurology (R.G.H.), University of Rochester Medical Center, NY
| | - Yue Li
- From the Department of Public Health Sciences, Division of Health Policy and Outcomes Research (Y.K., L.G.G., Y.L.), Department of Anesthesiology (L.G.G.), and Department of Neurology (R.G.H.), University of Rochester Medical Center, NY
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Glance LG, Thirukumaran CP, Li Y, Gao S, Dick AW. Improving The Accuracy Of Hospital Quality Ratings By Focusing On The Association Between Volume And Outcome. Health Aff (Millwood) 2020; 39:862-870. [PMID: 32364861 DOI: 10.1377/hlthaff.2019.00778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Centers for Medicare and Medicaid Services (CMS) uses hierarchical modeling to stabilize its hospital quality star ratings by shrinking the performance of low-volume hospitals toward the performance of average hospitals. Responding to criticism that the methodology may distort the performance of low-volume hospitals, a CMS expert panel recommended that the agency consider using "shrinkage targets" to more accurately classify hospital quality performance. To test the "shrinkage targets" approach, we created two parallel sets of performance measures. We found that there was moderate-to-substantial agreement between the standard CMS approach and the approach based on shrinkage targets in hospital star ratings for all but the lowest-volume hospitals. These findings suggest that the standard CMS risk-adjustment methodology does not distort the star ratings of hospitals as long as case volumes exceed the current cutoff (twenty-five cases) used by CMS for public reporting.
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Affiliation(s)
- Laurent G Glance
- Laurent G. Glance ( laurent_glance@urmc. rochester. edu ) is vice chair for research and a professor in the Department of Anesthesiology and Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, in New York
| | - Caroline P Thirukumaran
- Caroline P. Thirukumaran is an assistant professor in the Department of Orthopaedics and Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry
| | - Yue Li
- Yue Li is a professor in the Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry
| | - Shan Gao
- Shan Gao is an associate in the Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry
| | - Andrew W Dick
- Andrew W. Dick is a senior economist at RAND Health, RAND Corporation, in Boston, Massachusetts
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Thirukumaran CP, McGarry BE, Glance LG, Ying M, Ricciardi BF, Cai X, Li Y. Impact of Hospital Readmissions Reduction Program Penalties on Hip and Knee Replacement Readmissions: Comparison of Hospitals at Risk of Varying Penalty Amounts. J Bone Joint Surg Am 2020; 102:60-67. [PMID: 31613862 PMCID: PMC7292495 DOI: 10.2106/jbjs.18.01501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little is known about the impact of the U.S. Centers for Medicare & Medicaid Services' Hospital Readmissions Reduction Program (HRRP) expansion to include readmissions following elective primary total hip and knee replacements; the expansion was finalized in 2013 and was implemented in 2014. We examined whether hospitals at risk of relatively large penalties from this expansion experienced greater declines in joint replacement readmissions compared with hospitals at risk of smaller penalties. METHODS We used Medicare's 2009 to 2016 Hospital Compare data sets to examine the impact of the HRRP's expansion in the July 2013 to June 2016 period (post-expansion) compared with the July 2009 to June 2012 period (pre-expansion). The primary outcome was the hospital-level, 30-day, risk-standardized readmission rate (hereafter called the readmission rate) following joint replacement surgical procedures. We used the percentage of a hospital's total inpatient revenue attributed to Medicare (categorized into quartiles) to represent the risk of penalties. We used hierarchical linear regression models to examine the adjusted impact of the HRRP's expansion. RESULTS Our study cohort included 2,326 acute care hospitals. In the pre-HRRP expansion phase, the mean readmission rate was 5.36% among hospitals with the highest proportion of Medicare revenues (quartile 4) and 5.46% among hospitals with the lowest proportion of Medicare revenues (quartile 1). With the HRRP expansion, the readmission rate declined by 18.92% (1.01 percentage points) among quartile-4 hospitals and by 17.97% (0.98 percentage point) among quartile-1 hospitals (p = 0.45). This nonsignificant difference in readmission rate declines between quartiles persisted in multivariable analysis (a decline of 18.41% [0.98 percentage point] in quartile 4 and a decline of 17.35% [0.94 percentage point] in quartile 1; p = 0.35). CONCLUSIONS The HRRP's expansion to include joint replacements did not lead to greater reductions in postoperative readmissions among hospitals at risk of larger penalties in comparison with hospitals at risk of smaller penalties. Readmission rates were declining at similar rates among all hospitals, before and after the HRRP's expansion. CLINICAL RELEVANCE Readmissions and complications following joint replacements are measures of the quality of surgical care. These events have important clinical and economic implications for patients and providers. This study is clinically relevant because it examines whether policy interventions, such as the HRRP, have the potential to reduce these unintended consequences of surgical care.
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Affiliation(s)
| | | | | | | | | | - Xueya Cai
- University of Rochester, Rochester, New York
| | - Yue Li
- University of Rochester, Rochester, New York
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Thirukumaran CP, Glance LG, Cai X, Kim Y, Li Y. Penalties and Rewards for Safety Net vs Non-Safety Net Hospitals in the First 2 Years of the Comprehensive Care for Joint Replacement Model. JAMA 2019; 321:2027-2030. [PMID: 31135838 PMCID: PMC6547113 DOI: 10.1001/jama.2019.5118] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study compared monetary penalties and rewards among safety net vs non–safety net hospitals under Medicare’s Comprehensive Care for Joint Replacement (CJR) model, a bundled payment plan for hip and knee replacements intended to incentivize health care quality and savings, in 2016 and 2017.
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Affiliation(s)
| | - Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Yeunkyung Kim
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, Rochester, New York
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Osler T, Glance LG, Buzas JS, Hosmer DW. Injury scoring: Then, now, and into the 21st century. Injury 2019; 50:2-3. [PMID: 30609974 DOI: 10.1016/j.injury.2018.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Turner Osler
- Department of Surgery, University of Vermont, 789 Orchard Shore Road, Colchester, VT 05446, USA.
| | | | - Jeffrey S Buzas
- Department of Mathematics and Statistics, University of Vermont, USA
| | - David W Hosmer
- Department of Mathematics and Statistics, University of Vermont, USA
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Osler T, Yuan D, Holden J, Huang Z, Cook A, Glance LG, Buzas JS, Hosmer DW. Variation in readmission rates among hospitals following admission for traumatic injury. Injury 2019; 50:173-177. [PMID: 30170786 DOI: 10.1016/j.injury.2018.08.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/10/2018] [Accepted: 08/26/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Readmission following hospital discharge is both common and costly. The Hospital Readmission Reduction Program (HRRP) financially penalizes hospitals for readmission following admission for some conditions, but this approach may not be appropriate for all conditions. We wished to determine if hospitals differed in their adjusted readmission rates following an index hospital admission for traumatic injury. PATIENTS AND METHODS We extracted from the AHRQ National Readmission Dataset (NRD) all non-elderly adult patients hospitalized following traumatic injury in 2014. We estimated hierarchal logistic regression models to predicted readmission within 30 days. Models included either patient level predictors, hospital level predictors, or both. We quantified the extent of hospital variability in readmissions using the median odds ratio. Additionally, we computed hospital specific risk-adjusted rates of readmission and number of excess readmissions. RESULTS Of the 177,322 patients admitted for traumatic injury 11,940 (6.7%) were readmitted within 30 days. Unadjusted hospital readmission rates for the 637 hospitals in our study varied from 0% to 20%. After controlling for sources of variability the range for hospital readmission rates was between 5.5% and 8.5%. Only 2% of hospitals had a random intercept coefficient significantly different from zero, suggesting that their readmission rates differed from the mean level of all hospitals. We also estimated that in 2014 only 11% of hospitals had more than 2 excess readmissions. Our multilevel model discriminated patients who were readmitted from those not readmitted at an acceptable level (C = 0.74). CONCLUSIONS We found little evidence that hospitals differ in their readmission rates following an index admission for traumatic injury. There is little justification for penalizing hospitals based on readmissions after traumatic injury.
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Affiliation(s)
- Turner Osler
- University of Vermont, 789 Orchard Shore Road, Colchester, VT 05446, United States.
| | | | | | | | - Alan Cook
- Trauma Research Program, Chandler Regional Medical Center, United States
| | - Laurent G Glance
- Department of Anesthesiology, University of Rochester, United States
| | - Jeffrey S Buzas
- Department of Mathematics and Statistics, University of Vermont, United States
| | - David W Hosmer
- Department of Mathematics and Statistics, University of Vermont, United States
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Thirukumaran CP, Glance LG, Rosenthal MB, Temkin‐Greener H, Balkissoon R, Mesfin A, Li Y. Impact of Medicare's Nonpayment Program on Venous Thromboembolism Following Hip and Knee Replacements. Health Serv Res 2018; 53:4381-4402. [PMID: 30022482 PMCID: PMC6232432 DOI: 10.1111/1475-6773.13013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE To determine whether Medicare's Nonpayment Program was associated with decline in venous thromboembolism (VTE) following hip and knee replacements; and whether the decline was greater among hospitals at risk of larger financial losses from the Program. DATA SOURCES State Inpatient Database for New York (NY) from 2005 to 2013. STUDY DESIGN The primary outcome was an occurrence of VTE. Medicare Utilization Ratio (MUR), which is the proportion of inpatient days in a hospital that is financed by Medicare, represented a hospital's financial sensitivity. We used hierarchical logistic regressions with difference-in-differences estimation to study the Program effects. PRINCIPAL FINDINGS A total of 98,729 hip replacement and 111,361 knee replacement stays were identified. For hip replacement, the Program was associated with significant reduction (Range: 44% to 53%) in VTE incidence among hospitals in MUR quartiles 2 to 4. For knee replacement, the Program was associated with significant reduction (47%) in VTE incidence only among quartile 2 hospitals. CONCLUSION Implementation of the Program was associated with a reduction in VTE, especially for hip replacements, in higher MUR hospitals. Payment reforms such as Medicare's Nonpayment Program that withhold payments for complications are effective and should be continued.
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Affiliation(s)
| | | | - Meredith B. Rosenthal
- Department of Health Policy and ManagementHarvard T. H. Chan School of Public HealthBostonMA
| | | | | | - Addisu Mesfin
- Department of OrthopaedicsUniversity of RochesterRochesterNY
| | - Yue Li
- Department of Public Health SciencesUniversity of RochesterRochesterNY
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Glance LG, Faden E, Dutton RP, Lustik SJ, Li Y, Eaton MP, Dick AW. Impact of the Choice of Risk Model for Identifying Low-risk Patients Using the 2014 American College of Cardiology/American Heart Association Perioperative Guidelines. Anesthesiology 2018; 129:889-900. [DOI: 10.1097/aln.0000000000002341] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
The 2014 American College of Cardiology Perioperative Guideline recommends risk stratifying patients scheduled to undergo noncardiac surgery using either: (1) the Revised Cardiac Index; (2) the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator; or (3) the Myocardial Infarction or Cardiac Arrest calculator. The aim of this study is to determine how often these three risk-prediction tools agree on the classification of patients as low risk (less than 1%) of major adverse cardiac event.
Methods
This is a retrospective observational study using a sample of 10,000 patient records. The risk of cardiac complications was calculated for the Revised Cardiac Index and the Myocardial Infarction or Cardiac Arrest models using published coefficients, and for the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator using the publicly available website. The authors used the intraclass correlation coefficient and kappa analysis to quantify the degree of agreement between these three risk-prediction tools.
Results
There is good agreement between the American College of Surgeons National Surgical Quality Improvement Program and Myocardial Infarction or Cardiac Arrest estimates of major adverse cardiac events (intraclass correlation coefficient = 0.68, 95% CI: 0.66 to 0.70), while only poor agreement between (1) American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator and the Revised Cardiac Index (intraclass correlation coefficient = 0.37; 95% CI: 0.34 to 0.40), and (2) Myocardial Infarction or Cardiac Arrest and Revised Cardiac Index (intraclass correlation coefficient = 0.26; 95% CI: 0.23 to 0.30). The three prediction models disagreed 29% of the time on which patients were low risk.
Conclusions
There is wide variability in the predicted risk of cardiac complications using different risk-prediction tools. Including more than one prediction tool in clinical guidelines could lead to differences in decision-making for some patients depending on which risk calculator is used.
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Affiliation(s)
- Laurent G. Glance
- From the Department of Anesthesiology (L.G.G., E.F., S.J.L., M.P.E.) and the Department of Public Health Sciences (L.G.G., Y.L.), University of Rochester School of Medicine, Rochester, New York; RAND Health, Boston, Massachusetts (L.G.G., A.W.D.); and U.S. Anesthesia Partners, Dallas, Texas (R.P.D.)
| | - Eric Faden
- From the Department of Anesthesiology (L.G.G., E.F., S.J.L., M.P.E.) and the Department of Public Health Sciences (L.G.G., Y.L.), University of Rochester School of Medicine, Rochester, New York; RAND Health, Boston, Massachusetts (L.G.G., A.W.D.); and U.S. Anesthesia Partners, Dallas, Texas (R.P.D.)
| | - Richard P. Dutton
- From the Department of Anesthesiology (L.G.G., E.F., S.J.L., M.P.E.) and the Department of Public Health Sciences (L.G.G., Y.L.), University of Rochester School of Medicine, Rochester, New York; RAND Health, Boston, Massachusetts (L.G.G., A.W.D.); and U.S. Anesthesia Partners, Dallas, Texas (R.P.D.)
| | - Stewart J. Lustik
- From the Department of Anesthesiology (L.G.G., E.F., S.J.L., M.P.E.) and the Department of Public Health Sciences (L.G.G., Y.L.), University of Rochester School of Medicine, Rochester, New York; RAND Health, Boston, Massachusetts (L.G.G., A.W.D.); and U.S. Anesthesia Partners, Dallas, Texas (R.P.D.)
| | - Yue Li
- From the Department of Anesthesiology (L.G.G., E.F., S.J.L., M.P.E.) and the Department of Public Health Sciences (L.G.G., Y.L.), University of Rochester School of Medicine, Rochester, New York; RAND Health, Boston, Massachusetts (L.G.G., A.W.D.); and U.S. Anesthesia Partners, Dallas, Texas (R.P.D.)
| | - Michael P. Eaton
- From the Department of Anesthesiology (L.G.G., E.F., S.J.L., M.P.E.) and the Department of Public Health Sciences (L.G.G., Y.L.), University of Rochester School of Medicine, Rochester, New York; RAND Health, Boston, Massachusetts (L.G.G., A.W.D.); and U.S. Anesthesia Partners, Dallas, Texas (R.P.D.)
| | - Andrew W. Dick
- From the Department of Anesthesiology (L.G.G., E.F., S.J.L., M.P.E.) and the Department of Public Health Sciences (L.G.G., Y.L.), University of Rochester School of Medicine, Rochester, New York; RAND Health, Boston, Massachusetts (L.G.G., A.W.D.); and U.S. Anesthesia Partners, Dallas, Texas (R.P.D.)
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Affiliation(s)
- Laurent G Glance
- Departments of Anesthesiology and Public Health Sciences, University of Rochester School of Medicine, Rochester, New York RAND Health, RAND, Boston, Massachusetts, US Anesthesia Partners, Dallas, Texas Department of Biostatistics and Computational Biology, University of Rochester School of Medicine, Rochester, New York Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York Department of Anesthesiology, University of Rochester School of Medicine, Rochester, New York RAND Health, RAND, Boston, Massachusetts
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Li Y, Cen X, Cai X, Thirukumaran CP, Zhou J, Glance LG. Medicare Advantage Associated With More Racial Disparity Than Traditional Medicare For Hospital Readmissions. Health Aff (Millwood) 2017. [PMID: 28637771 DOI: 10.1377/hlthaff.2016.1344] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We compared racial disparities in thirty-day readmissions between traditional Medicare and Medicare Advantage beneficiaries who underwent one of six major surgeries in New York State in 2013. We found that Medicare Advantage was associated with greater racial disparity, compared to traditional Medicare. After controlling for patient, hospital, and geographic characteristics in a propensity score based approach, we found that in traditional Medicare, black patients were 33 percent more likely than white patients to be readmitted, whereas in Medicare Advantage, black patients were 64 percent more likely than white patients to be readmitted. Our findings suggest that the risk-reduction strategies adopted by Medicare Advantage plans have not been successful in lowering the markedly higher rate of readmission among black patients, compared to white patients.
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Affiliation(s)
- Yue Li
- Yue Li is an associate professor in the Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, in New York
| | - Xi Cen
- Xi Cen is a PhD candidate in the Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry
| | - Xueya Cai
- Xueya Cai is a research associate professor in the Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry
| | - Caroline P Thirukumaran
- Caroline P. Thirukumaran is an assistant professor in the Department of Orthopaedics and Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry
| | - Jie Zhou
- Jie Zhou is an assistant professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Harvard Medical School and Brigham and Women's Hospital, both in Boston, Massachusetts
| | - Laurent G Glance
- Laurent G. Glance is vice chair for research and a professor in the Department of Anesthesiology and Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry
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Glance LG, Li Y, Dick AW. Impact on hospital ranking of basing readmission measures on a composite endpoint of death or readmission versus readmissions alone. BMC Health Serv Res 2017; 17:327. [PMID: 28476128 PMCID: PMC5420148 DOI: 10.1186/s12913-017-2266-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 04/25/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Readmission penalties are central to the Centers for Medicare and Medicaid Services (CMS) efforts to improve patient outcomes and reduce health care spending. However, many clinicians believe that readmission metrics may unfairly penalize low-mortality hospitals because mortality and readmission are competing risks. The objective of this study is to compare hospital ranking based on a composite outcome of death or readmission versus readmission alone. METHODS We performed a retrospective observational study of 344,565 admissions for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumoniae (PNEU) using population-based data from the New York State Inpatient Database (NY SID) between 2011 and 2013. Hierarchical logistic regression modeling was used to estimate separate risk-adjustment models for the (1) composite outcome (in-hospital death or readmission within 7-days), and (2) 7-day readmission. Hospital rankings based on the composite measure and the readmission measure were compared using the intraclass correlation coefficient and kappa analysis. RESULTS Using data from all AMI, CHF, and PNEU admissions, there was substantial agreement between hospital adjusted odds ratio (AOR) based on the composite outcome versus the readmission outcome (intraclass correlation coefficient [ICC] 0.67; 95% CI: 0.56, 0.75). For patients admitted with AMI, there was moderate agreement (ICC 0.53; 95% CI: 0.41, 0.62); for CHF, substantial agreement (ICC 0.72; 95% CI: 0.66, 0.78); and for PNEU, substantial agreement (ICC 0.71; 95% CI: 0.61, 0.78). There was moderate agreement when the composite and readmission metrics were used to classify hospitals as high, average, and low-performance hospitals (κ = 0.54, SE = 0.050). For patients admitted with AMI, there was slight agreement (κ = 0.14, SE = 0.037) between the two metrics. CONCLUSIONS Hospital performance on readmissions is significantly different from hospital performance on a composite metric based on readmissions and mortality. CMS and policy makers should consider re-assessing the use of readmission metrics for measuring hospital performance.
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Affiliation(s)
- Laurent G Glance
- Department of Anesthesiology, University of Rochester School of Medicine, Rochester, USA. .,RAND Health, RAND, Boston, USA. .,Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, USA.
| | - Yue Li
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, USA
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Li Y, Cen X, Cai X, Wang D, Thirukumaran CP, Glance LG. Does Medicare Advantage Reduce Racial Disparity in 30-Day Rehospitalization for Medicare Beneficiaries? Med Care Res Rev 2016; 75:175-200. [DOI: 10.1177/1077558716681938] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study determined potential racial and ethnic disparities in risk for all-cause 30-day readmission among traditional Medicare (TM) and Medicare Advantage (MA) beneficiaries initially hospitalized for acute myocardial infarction, congestive heart failure, or pneumonia. Our analyses of New York State hospital administrative data between 2009 and 2012 found that overall 30-day readmission rate declined from 22.0% in 2009 to 20.7% in 2012 for TM beneficiaries, and from 20.2% in 2009 to 17.9% in 2012 for MA beneficiaries. However, persistent racial disparities were found in propensity-score–based analyses among TM beneficiaries (e.g., in 2012, adjusted odds ratio [OR] = 1.11, 95% confidence interval [CI] = 1.01-1.23, p = .029), though not among MA beneficiaries (in 2012, adjusted OR = 1.05, 95% CI = 0.92-1.19, p = .476). We did not find evidence of persistent ethnic disparity for TM (in 2012, adjusted OR = 1.08, 95% CI = 0.93-1.25, p = .303) or MA (in 2012, adjusted OR = 0.99, 95% CI = 0.88-1.11, p = .837) beneficiaries. We conclude that enrollment in MA seemed to be associated with significantly reduced readmission rate and potentially reduced racial disparity.
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Affiliation(s)
- Yue Li
- University of Rochester Medical Center, Rochester, NY, USA
| | - Xi Cen
- University of Rochester Medical Center, Rochester, NY, USA
| | - Xueya Cai
- University of Rochester Medical Center, Rochester, NY, USA
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Osler T, Cook A, Glance LG, Lecky F, Bouamra O, Garrett M, Buzas JS, Hosmer DW. The differential mortality of Glasgow Coma Score in patients with and without head injury. Injury 2016; 47:1879-85. [PMID: 27129906 DOI: 10.1016/j.injury.2016.04.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 03/25/2016] [Accepted: 04/13/2016] [Indexed: 02/02/2023]
Abstract
IMPORTANCE The GCS was created forty years ago as a measure of impaired consciousness following head injury and thus the association of GCS with mortality in patients with traumatic brain injury (TBI) is expected. The association of GCS with mortality in patients without TBI (non-TBI) has been assumed to be similar. However, if this assumption is incorrect mortality prediction models incorporating GCS as a predictor will need to be revised. OBJECTIVE To determine if the association of GCS with mortality is influenced by the presence of TBI. DESIGN/SETTING/PARTICIPANTS Using the National Trauma Data Bank (2012; N=639,549) we categorized patients as isolated TBI (12.8%), isolated non-TBI (33%), both (4.8%), or neither (49.4%) based on the presence of AIS codes of severity 3 or greater. We compared the ability GCS to discriminate survivors from non-survivors in TBI and in non-TBI patients using logistic models. We also estimated the odds ratios of death for TBI and non-TBI patients at each value of GCS using linear combinations of coefficients. MAIN OUTCOME MEASURE Death during hospital admission. RESULTS As the sole predictor in a logistic model GCS discriminated survivors from non-survivors at an acceptable level (c-statistic=0.76), but discriminated better in the case of TBI patients (c-statistic=0.81) than non-TBI patients (c-statistic=0.70). In both unadjusted and covariate adjusted models TBI patients were about twice as likely to die as non-TBI patients with the same GCS for GCS values<8; for GCS values>8 TBI and non-TBI patients were at similar risk of dying. CONCLUSIONS A depressed GCS predicts death better in TBI patients than non-TBI patients, likely because in non-TBI patients a depressed GCS may simply be the result of entirely reversible intoxication by alcohol or drugs; in TBI patients, by contrast, a depressed GCS is more ominous because it is likely due to a head injury with its attendant threat to survival. Accounting for this observation into trauma mortality datasets and models may improve the accuracy of outcome prediction.
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Affiliation(s)
- Turner Osler
- Department of Surgery, University of Vermont, 789 Orchard Shore Road, Colchester, VT 05446, United States.
| | - Alan Cook
- Trauma Research Program, Chandler Regional Medical Center, United States; Department of Surgery University of Arizona College of Medicine, Phoenix, United States.
| | - Laurent G Glance
- Department of Anesthesiology, University of Rochester, United States.
| | - Fiona Lecky
- Emergency Medicine, University of Sheffield, United Kingdom; Trauma Audit and Research Network, United Kingdom.
| | - Omar Bouamra
- Trauma Audit and Research Network, United Kingdom.
| | - Mark Garrett
- Chandler Regional Medical Center, United States.
| | - Jeffery S Buzas
- Department of Mathematics and Statistics, University of Vermont, United States.
| | - David W Hosmer
- School of Public Health and Health Sciences, University of Massachusetts, United States.
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Xing J, Mukamel DB, Glance LG, Zhang N, Temkin-Greener H. Medicaid Reimbursement and the Quality of Nursing Home Care: A Case Study of Medi-Cal Long-Term Care Reimbursement Act of 2004 in California. WHM 2016. [DOI: 10.1002/wmh3.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Glance LG, Hannan EL, Fleisher LA, Eaton MP, Dutton RP, Lustik SJ, Li Y, Dick AW. Feasibility of Report Cards for Measuring Anesthesiologist Quality for Cardiac Surgery. Anesth Analg 2016; 122:1603-13. [DOI: 10.1213/ane.0000000000001252] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
OBJECTIVES To examine racial and site-of-care disparities in all-cause and potentially avoidable 30-day rehospitalization rates among a national cohort of Medicare skilled nursing facility (SNF) residents. METHODS We analyzed the 2012 Minimum Data Set, Medicare inpatient claims, and other data. Multivariable logistic regressions were used to adjust for resident demographic, functional, and diagnostic characteristics, as well as observed SNF and geographic factors. Conditional fixed effects for SNFs were further used to adjust for both observed and unobserved factors. Independent effects of black race and site-of-care groups were estimated, where sites were defined using proportions of black Medicare admissions to the SNF. RESULTS The 30-day all-cause and potentially avoidable rehospitalization rates were 21.9% and 8.8%, respectively, for black residents (n=120,508), and 17.7% and 7.9% for white residents (n=1,182,003). Racial disparities persisted after adjustment for resident characteristics. Moreover, risk-adjusted disparities were essentially related to the type of SNFs to which residents were admitted; after controlling for SNF sites, significant racial disparity disappeared for potentially available rehospitalizations. Black residents and white residents admitted to SNFs with high proportions of black admissions (>25%) were 31% and 19%, respectively, more likely to be rehospitalized than white residents admitted to SNFs caring for only a small percentage of black postacute residents (<3%). CONCLUSIONS Compared with white SNF residents, black SNF residents are more likely to be rehospitalized even after adjusting for patient risk factors. Black-white disparities, especially in potentially preventable rehospitalizations, are largely due to the fact that black residents tend to be admitted to the small number of SNFs with very high rehospitalization rates.
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Affiliation(s)
- Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center
| | - Laurent G. Glance
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
- Department of Anesthesiology, University of Rochester Medical Center
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Affiliation(s)
- Turner Osler
- Department of Surgery, University of Vermont, Colchester
| | - Laurent G. Glance
- Department of Anesthesiology, University of Rochester, Rochester, New York
| | - Wenjun Li
- Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Jeffery S. Buzas
- Department of Mathematics and Statistics, University of Vermont, Burlington
| | - David W. Hosmer
- School of Public Health and Health Sciences, University of Massachusetts, Worcester
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Glance LG, Kellermann AL, Hannan EL, Fleisher LA, Eaton MP, Dutton RP, Lustik SJ, Li Y, Dick AW. The impact of anesthesiologists on coronary artery bypass graft surgery outcomes. Anesth Analg 2015; 120:526-533. [PMID: 25695571 DOI: 10.1213/ane.0000000000000522] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND One of every 150 hospitalized patients experiences a lethal adverse event; nearly half of these events involves surgical patients. Although variations in surgeon performance and quality have been reported in the literature, less is known about the influence of anesthesiologists on outcomes after major surgery. Our goal of this study was to determine whether there is significant variation in outcomes between anesthesiologists after controlling for patient case mix and hospital quality. METHODS Using clinical data from the New York State Cardiac Surgery Reporting System, we conducted a retrospective observational study of 7920 patients undergoing isolated coronary artery bypass graft surgery. Multivariable logistic regression modeling was used to examine the variation in death or major complications (Q-wave myocardial infarction, renal failure, stroke) across anesthesiologists, controlling for patient demographics, severity of disease, comorbidities, and hospital quality. RESULTS Anesthesiologist performance was quantified using fixed-effects modeling. The variability across anesthesiologists was highly significant (P < 0.001). Patients managed by low-performance anesthesiologists (corresponding to the 25th percentile of the distribution of anesthesiologist risk-adjusted outcomes) experienced nearly twice the rate of death or serious complications (adjusted rate 3.33%; 95% confidence interval [CI], 3.09%-3.58%) as patients managed by high-performance anesthesiologists (corresponding to the 75th percentile) (adjusted rate 1.82%; 95% CI, 1.58%-2.10%). This performance gap was observed across all patient risk groups. CONCLUSIONS The rate of death or major complications among patients undergoing coronary artery bypass graft surgery varies markedly across anesthesiologists. These findings suggest that there may be opportunities to improve perioperative management to improve outcomes among high-risk surgical patients.
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Affiliation(s)
- Laurent G Glance
- From the Departments of *Anesthesiology and #Public Health Sciences, University of Rochester School of Medicine, Rochester, New York; †RAND Health, RAND, Boston, Massachusetts; ‡F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; §School of Public Health, University at Albany, State University of New York, Albany, New York; ‖Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania; and ¶Anesthesia Quality Institute, Park Ridge, Illinois
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