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Paladugu A, Donnelly M, Grigorian A, Swentek L, Kuza C, Yamamoto K, Shipley J, Nguyen N, Nahmias J. Inpatient Cost of Trauma Care Versus Repair of Elective Open Inguinal Hernias: Nationwide Trends Over Nearly a Decade. Am Surg 2025; 91:807-812. [PMID: 39837797 DOI: 10.1177/00031348251313995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2025]
Abstract
Purpose: Concerns exist regarding increased trauma activation fees at the expense of vulnerable patients. In contrast, elective open inguinal hernia repair (E-OIHR) has remained relatively fixed in terms of technique. This study aimed to examine health care costs for E-OIHR and trauma patients, hypothesizing trauma cost would increase from 2010 to 2018, while E-OIHR cost would remain unchanged. Methods: The Nationwide Inpatient Sample database was queried (2010-2018) for admitted patients undergoing unilateral E-OIHR or trauma-related admission. Health care costs per admission, total annual costs, and trends of E-OIHR and trauma admissions were also examined. Multiple linear regression was used to estimate the association of individual- and hospital-level variables with total costs. Results: Unilateral E-OIHR admission cost more than doubled per case in 2018. Trauma cost per admission also increased, however, only by 34%. Total costs for all E-OIHR admissions increased 26%, whereas trauma admission costs increased 32%. Both trauma admissions and unilateral E-OIHR admissions decreased; however, E-OIHR admissions decreased more. Multiple linear regression demonstrated compared to the cost of E-OIHR, trauma care decreased when adjusting for year, age, severity, hospital type, and length of stay (P < .001). Conclusion: The rate of increase in cost per unilateral E-OIHR admission exceeded that of trauma. However, the total economic burden for trauma care increased by billions of dollars due to a steady increase in per incidence cost and only slightly lower rates of trauma admissions. Increased focus on high-value care to curtail increasing costs of E-OIHR and especially trauma appears warranted.
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Affiliation(s)
- Anushka Paladugu
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Megan Donnelly
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Lourdes Swentek
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Catherine Kuza
- Department of Anesthesiology, University of Southern California, Los Angeles, CA, USA
| | - Kurt Yamamoto
- Center for Statistical Consulting, University of California, Irvine, Orange, CA, USA
| | - Jonathan Shipley
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Ninh Nguyen
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine, Orange, CA, USA
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Sears S, Mitchell D, Sammarco A, Sheyn D. Relationship between patient safety indicator events and hospital location for inpatient hysterectomy. Minerva Obstet Gynecol 2025; 77:67-74. [PMID: 38512347 DOI: 10.23736/s2724-606x.24.05431-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
BACKGROUND Previous studies suggest surgical quality outcomes are similar between rural and urban hospitals, but data about gynecology in rural hospitals is sparse. METHODS This was a retrospective cohort study utilizing the National Inpatient Sample database from the Agency of Healthcare Research and Quality. Patients who underwent benign hysterectomy for non-prolapse indications between 2012-2016 were identified using ICD-9 and 10 codes. Patients were stratified into rural or urban non-teaching groups; urban teaching hospitals were the referent group. The primary outcome was the rate of patient safety indicator (PSI) events. PSI events were identified using ICD-9 and 10 codes. Statistical analysis was performed using analysis of variance and uni- and multivariate Poisson regressions. RESULTS 154,810 patients met all inclusion criteria. The cumulative rate of PSI events was 11.9% at rural hospitals, 13.9% at urban non-teaching hospitals and 16.9% at urban teaching hospitals, P<0.001. The most common PSI events were postoperative metabolic derangement, hemorrhage, and accidental puncture. The rate of transfusion was highest in urban teaching hospitals (6.7%) and similar for rural (5.1%) and urban non-teaching hospitals (5.5%), P<0.001. The rate of genitourinary tract injury was between 1.4-1.6%, and similar across sites, P=0.89. After adjusting for confounders, the risk of PSI events was similar across locations. The risk of transfusion was lower at rural hospitals (aRR=0.84, 95% CI: 0.74-0.94). CONCLUSIONS Hysterectomy performed at rural hospitals, typically thought of as having low surgical volume compared to urban hospitals, is associated with similar risk of PSI events and lower risk of transfusion.
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Affiliation(s)
- Sarah Sears
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, USA -
| | - Diana Mitchell
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, USA
| | - Anne Sammarco
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - David Sheyn
- Institute of Urology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Ono R, Tominaga T, Nonaka T, Shiraishi T, Hashimoto S, Noda K, Araki M, Sumida Y, Takeshita H, Fukuoka H, Oyama S, Ishimaru K, Matsumoto K. Comparison of Short-Term Outcomes of Colorectal Cancer Surgery Performed by Male and Female Surgeons: A Japanese Multicenter Study. Asian J Endosc Surg 2025; 18:e70017. [PMID: 39743762 DOI: 10.1111/ases.70017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2024] [Revised: 11/30/2024] [Accepted: 12/22/2024] [Indexed: 01/04/2025]
Abstract
INTRODUCTION The number of female doctors is increasing worldwide, but the percentage of female general surgeons and gastrointestinal surgeons remains low, at only 6% in Japan. Furthermore, in rural areas, the number of doctors is small and training opportunities are limited, and training in surgical techniques is reportedly inadequate compared with urban areas. This study examined the current status and surgical outcomes of colorectal cancer surgery by surgeon sex using a multicenter database in a Japanese rural area. METHODS We retrospectively reviewed 3440 consecutive patients who underwent laparoscopic colorectal surgery in six participating hospitals between April 2016 and March 2023. Clinical and perioperative outcomes were compared between patients who underwent surgery by a male surgeon (M group; n = 3142) or by a female surgeon (F group; n = 298). RESULTS Years of experience as a doctor was significantly shorter (M group vs. F group: 12 years vs. 9 years, p < 0.001), frequency of participation of an expert surgeon was higher (79.9% vs. 89.9%, p = 0.038), frequency of preoperative treatment was lower (8.2% vs. 2.3%, p < 0.001), clinical T status was lower (p = 0.011), and re-operation rate was lower (3.1% vs. 1.0%, p = 0.045) in the F group. Multivariate analysis of clinical factors predicting postoperative severe complications revealed comorbidities (odds ratio 1.442, 95% confidence interval 1.045-1.990, p = 0.025) as an independent predictor of severe postoperative complications but not the presence of a female surgeon. CONCLUSION Female surgeons in our study achieved comparable short-term outcomes to male surgeons, including for laparoscopic procedures. Establishing an educational system in rural areas could provide improved surgical techniques.
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Affiliation(s)
- Rika Ono
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
- Department of Surgery, Sasebo City General Hospital, Sasebo, Japan
| | - Tetsuro Tominaga
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Takashi Nonaka
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Toshio Shiraishi
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | | | - Keisuke Noda
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Masato Araki
- Department of Surgery, Sasebo City General Hospital, Sasebo, Japan
| | - Yorihisa Sumida
- Department of Surgery, Sasebo City General Hospital, Sasebo, Japan
| | - Hiroaki Takeshita
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | | | - Shosaburo Oyama
- Department of Surgery, Ureshino Medical Center, Ureshino, Japan
| | | | - Keitaro Matsumoto
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
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Howell EC, Sakai-Bizmark R, Karunungan K, Pak Y, Ugarte R, Richardson S, DeUgarte DA, Lee SL. Disparities in outpatient rural cholecystectomy outcomes. Am J Surg 2024; 236:115852. [PMID: 39106552 PMCID: PMC11681941 DOI: 10.1016/j.amjsurg.2024.115852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 06/25/2024] [Accepted: 07/17/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND Previous studies showed comparable outcomes for common in-patient general surgery operations, but it is unknown if this extends to outpatient operations. Our aim was to compare outpatient cholecystectomy outcomes between rural and urban hospitals. METHODS A retrospective cohort analysis was done using the Nationwide Ambulatory Surgery Sample for patients 20-years-and-older undergoing cholecystectomy between 2016 and 2018 at rural and urban hospitals. Survey-weighted multivariable regression analysis was performed with primary outcomes including use-of-laparoscopy, complications, and patient discharge disposition. RESULTS The most common indication for operation was cholecystitis in both hospital settings. On multivariable analysis, rural hospitals were associated with higher transfers to short-term hospitals (adjusted odds ratio [aOR] 2.40, 95%CI 1.61-3.58, p < 0.01) and complications (aOR 1.39, 95%CI 1.11-1.75, p < 0.01). No difference was detected with laparoscopy (aOR 1.93, 95%CI 0.73-5.13, p = 0.19), routine discharge (aOR 1.50, 95%C I0.91-2.45, p = 0.11), or mortality (aOR 3.23, 95%CI 0.10-100.0, p = 0.51). CONCLUSIONS Patients cared for at rural hospitals were more likely to be transferred to short-term hospitals and have higher complications. No differences were detected in laparoscopy, routine discharge or mortality.
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Affiliation(s)
- Erin C Howell
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, 90502, USA; Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.
| | - Rie Sakai-Bizmark
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, 90502, USA; Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, CA, 90502, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.
| | | | - Yongju Pak
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, 90502, USA.
| | - Ramsey Ugarte
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, 90502, USA.
| | | | - Daniel A DeUgarte
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, 90502, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA; Division of Pediatric Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Steven L Lee
- Division of Pediatric Surgery, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA.
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Diaz A, Pawlik TM. Poverty and Its Impact on Surgical Care. Adv Surg 2024; 58:35-47. [PMID: 39089785 DOI: 10.1016/j.yasu.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
In this article, the authors explore the intricate relationship between poverty and surgical care, underscoring its multifaceted nature and its profound impact on access and outcomes. Poverty extends beyond financial constraints to encompass barriers related to healthcare infrastructure, geographic isolation, education, mental health, and social determinants of health, resulting in persistent disparities in access to high-quality surgical care, especially for those in persistently impoverished areas and access-sensitive surgical conditions. Additionally, the authors delve into the complex intersection of poverty, race, and ethnicity, emphasizing the heightened risks faced by minority patients in surgical care.
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Affiliation(s)
- Adrian Diaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH 43210, USA.
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Khan MMM, Munir MM, Thammachack R, Endo Y, Altaf A, Woldesenbet S, Rashid Z, Khalil M, Dillhoff M, Tsai S, Pawlik TM. Association of county-level provider density with hepatobiliary cancer incidence and mortality. World J Surg 2024; 48:2243-2252. [PMID: 39148145 DOI: 10.1002/wjs.12316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 08/05/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND Access to healthcare providers is a key factor in reducing cancer incidence and mortality, underscoring the significance of provider density as a crucial metric of health quality. We sought to characterize the association of provider density on hepatobiliary cancer population-level incidence and mortality. STUDY DESIGN County-level hepatobiliary cancer incidence and mortality data from 2016 to 2020 and provider data from 2016 to 2018 were obtained from the CDC and Area Health Resource File. Multivariable logistic regression was utilized to evaluate the relationship between provider density and hepatobiliary cancer incidence and mortality. RESULTS Among 1359 counties, 851 (62.6%) and 508 (37.4%) counties were categorized as urban and rural, respectively. The median number of providers in any given county was 104 (IQR: 44-306), while provider density was 120.1 (IQR: 86.7-172.2) per 100,000 population; median household income was $51,928 (IQR: $45,050-$61,655). Low provider-density counties were more likely to have a greater proportion of residents over 65 years of age (52.7% vs. 49.6%) who were uninsured (17.4% vs. 13.2%) versus higher provider-density counties (p < 0.05). Moreover, all-stage incidence, late-stage incidence, and mortality rates were higher in counties with low provider density. On multivariable analysis, moderate, and high provider density were associated with lower odds of all-stage incidence, late-stage incidence, and mortality. CONCLUSION Higher county-level provider density was associated with lower hepatobiliary cancer-related incidence and mortality. Efforts to increase access to healthcare providers may improve healthcare equity as well as long-term cancer outcomes.
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Affiliation(s)
- Muhammad Muntazir Mehdi Khan
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Muhammad Musaab Munir
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Razeen Thammachack
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Yutaka Endo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Abdullah Altaf
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Selamawit Woldesenbet
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Zayed Rashid
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mujtaba Khalil
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Susan Tsai
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
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Tran QK, Ternovskaia A, Downing JV, Cheema M, Kowansky T, Vashee I, Sayal J, Wu J, Singh A, Haase DJ. The Impact of the Critical Care Resuscitation Unit on Quaternary Care Accessibility for Rural Patients: A Comparative Analysis. Crit Care Res Pract 2024; 2024:9599855. [PMID: 39220227 PMCID: PMC11362575 DOI: 10.1155/2024/9599855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 07/06/2024] [Indexed: 09/04/2024] Open
Abstract
Background Previous research suggests that patients from rural areas who are critically ill with complex medical needs or require time-sensitive subspecialty interventions face worse healthcare outcomes and delays in care when compared to those from urban areas. The critical care resuscitation unit (CCRU) at our quaternary care center was established to expedite the transfer of critically ill patients or those who need time-sensitive intervention. This study investigates if disparities exist in treatments and outcomes among patients transferred to the CCRU from rural versus urban hospitals. Methods This is a retrospective study of adult, nontrauma patients admitted to the CCRU via interhospital transfer from outside facilities from January 1 to December 31, 2018. Patients transferred from within our institution or with missing clinical data were excluded. Multivariable logistic regressions were performed to measure the association between patients' demographic and clinical factors with in-hospital mortality. Results We analyzed 1381 nontrauma patients, and 484 (35%) were from rural areas. Median age was 59 [47-69], and 629 (46%) were female. Median sequential organ failure assessment was 3 ([1-6], p=0.062) for both patients transferred from urban and rural hospitals. There was no significant difference between groups with respect to most demographic and clinical factors, as well as types of interventions after CCRU arrival, including emergent surgical interventions within 12 hours of arrival at the CCRU. Rural patients were more likely to be transferred for care by the acute care emergency surgery service than were patients from urban areas and were transferred over a significantly greater distance (difference of 53 kilometers (km), 95% CI: -58.9-51.7 km, P < 0.001). Transfer from rural areas was not associated with increased odds of in-hospital mortality (OR: 0.90, 95% CI: 0.60, 1.36; P=0.63). Conclusion Thirty-five percent of patients transferred to the CCRU came from rural areas, which house 25% of the state population of Maryland. Patients transferred from rural counties to the CCRU faced greater transport distances, but they received the same level of care upon arrival at the CCRU and had the same odds of in-hospital mortality as patients transferred from urban hospitals.
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Affiliation(s)
- Quincy K. Tran
- Department of Emergency MedicineUniversity of Maryland School of Medicine, Baltimore, MD, USA
- The R Adams Cowley Shock Trauma CenterUniversity of Maryland School of Medicine, Baltimore, MD, USA
- The Research Associate Program in Emergency Medicine and Critical CareDepartment of Emergency MedicineUniversity of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anastasia Ternovskaia
- The Research Associate Program in Emergency Medicine and Critical CareDepartment of Emergency MedicineUniversity of Maryland School of Medicine, Baltimore, MD, USA
| | - Jessica V. Downing
- Department of Emergency MedicineUniversity of Maryland School of Medicine, Baltimore, MD, USA
- The R Adams Cowley Shock Trauma CenterUniversity of Maryland School of Medicine, Baltimore, MD, USA
- The Research Associate Program in Emergency Medicine and Critical CareDepartment of Emergency MedicineUniversity of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Minahil Cheema
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Taylor Kowansky
- The Research Associate Program in Emergency Medicine and Critical CareDepartment of Emergency MedicineUniversity of Maryland School of Medicine, Baltimore, MD, USA
| | - Isha Vashee
- The Research Associate Program in Emergency Medicine and Critical CareDepartment of Emergency MedicineUniversity of Maryland School of Medicine, Baltimore, MD, USA
| | - Jasjot Sayal
- The Research Associate Program in Emergency Medicine and Critical CareDepartment of Emergency MedicineUniversity of Maryland School of Medicine, Baltimore, MD, USA
| | - Jasmine Wu
- The R Adams Cowley Shock Trauma CenterUniversity of Maryland School of Medicine, Baltimore, MD, USA
| | - Aditi Singh
- The Research Associate Program in Emergency Medicine and Critical CareDepartment of Emergency MedicineUniversity of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel J. Haase
- Department of Emergency MedicineUniversity of Maryland School of Medicine, Baltimore, MD, USA
- The R Adams Cowley Shock Trauma CenterUniversity of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
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Branche C, Chervu N, Porter G, Vadlakonda A, Sakowitz S, Ali K, Mallick S, Benharash P. The impact of rurality on racial disparities in costs of bowel obstruction treatment. Surg Open Sci 2024; 20:27-31. [PMID: 38873333 PMCID: PMC11170271 DOI: 10.1016/j.sopen.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 05/24/2024] [Indexed: 06/15/2024] Open
Abstract
Background Black race has been associated with increased resource utilization after operation for small bowel obstruction (SBO). While prior literature has similarly demonstrated differences between urban and rural institutions, limited work has defined the impact of rurality on resource utilization by race. Methods The 2016-2020 National Inpatient Sample was used to identify adults undergoing adhesiolysis after non-elective admission for SBO. The primary endpoint was hospitalization costs. Additional outcomes included surgical delay (≥ hospital day 3), length of stay (LOS), and nonhome discharge. Regression models were developed to identify the impact of Black race and rurality on the outcomes of interest with an interaction term to examine the incremental association of Black race on rurality. Results Of an estimated 132,390 patients, 11.4 % were treated at an annual average of 377 rural hospitals (18.5 % of institutions). After adjustment, rural hospitals had higher costs (β + $4900, 95 % Confidence Interval [CI] [4200, 5700]), compared to others. However, rurality was associated with reduced odds of surgical delay (Adjusted Odds Ratio [AOR] 0. 76, CI[0.69, 0.85]), decreased LOS (β -1.66 days, CI[-1.99, -1.36]), and nonhome discharge (AOR 0.78, CI[0.70, 0.87]). While White patients experienced significant cost reductions at urban centers ($26,100 [25,800-26,300] vs $31,000 [30,300-31,700]), this was not noted for Black patients ($30,100 [29,400-30,700] vs $30,800 [29,300-32,400]). Conclusions We found that Black patients do not benefit from the same cost protection afforded by urban settings as White patients after operative SBO admission. Future work should focus on setting-specific interventions to address drivers of disparities within each community.
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Affiliation(s)
- Corynn Branche
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Nikhil Chervu
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, USA
| | - Giselle Porter
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Amulya Vadlakonda
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Sara Sakowitz
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Konmal Ali
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Saad Mallick
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, USA
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Wen J, Alam M, Ansari U, Shehabat M, Syed B, Akhtar M, Razick D, Puglisi J, Wang A. Where Will I Go? Relative Location of Physical Medicine and Rehabilitation Residencies Compared With Medical Schools Among Recent Residents. Am J Phys Med Rehabil 2024; 104:70-76. [PMID: 38954788 DOI: 10.1097/phm.0000000000002574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
ABSTRACT Physical medicine and rehabilitation has rapidly been garnering interest as health care increases the emphasis on rehabilitation and management for acute and chronic diseases. This study analyzes recent geographical trends of physical medicine and rehabilitation residents via physical medicine and rehabilitation residents from 2019 to 2023, which were identified from publicly available data. The relative distribution from medical school to residency, medical school to preliminary program, and preliminary program to residency were analyzed. These locations were categorized as within 100 miles, same state, same region, or different region. Odds ratio were calculated for the aforementioned relative locations with respect to the presence of a home residency program. A total of 1836 residents were included. The majority of residents (51%) stayed within the same region as their medical school. Residents from medical schools with a home program were more likely to stay within 100 miles (odds ratio: 3.64), the same state (odds ratio: 3.19), and same region (odds ratio: 2.56). Overall, physical medicine and rehabilitation residents are likely to stay within the same region as their medical school and preliminary year. In addition, the presence of a home program significantly increases the odds of matching within 100 miles, same state, and same region.
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Affiliation(s)
- Jimmy Wen
- From the California Northstate University College of Medicine, Elk Grove, California (JW, MA, UA, MS, BS, MA, DR, JP); and Department of Physical Medicine and Rehabilitation, University of California Davis, Sacramento, California (AW)
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Wu SS, Rathi VK, Byrne PJ, Fritz MA, Shaye DA, Lee LN, Sethi RKV, Lindsay RW, Xiao R. Variations in Payer-Negotiated Prices for Head and Neck Reconstructive Surgery. Otolaryngol Head Neck Surg 2023; 169:1154-1162. [PMID: 37337449 DOI: 10.1002/ohn.407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/26/2023] [Accepted: 05/27/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE Little is known about pricing for reconstructive procedures of the head and neck. As of January 2021, the Centers for Medicare and Medicaid Services requires hospitals to disclose payer-negotiated prices for services, offering new insight into prices for privately insured patients. STUDY DESIGN Cross-sectional analysis. SETTING Turquoise database. METHODS Payer-negotiated facility fees for 41 reconstructive surgeries were grouped by procedure type: primary closure, skin grafts, tissue rearrangement, locoregional flaps, or free flaps. Prices were normalized to account for local labor costs, then calculated as percent markup in excess of Medicare reimbursement. The mean percent markup between procedure groups was compared by the Kruskal-Wallis test. Subset analyses were performed to compare mean percent markup using a Student's t test. We also assessed price variation by calculating the ratio of 90th/10th percentile mean prices both across and within hospitals. RESULTS In total, 1324 hospitals (85% urban, 81% nonprofit, 49% teaching) were included. Median payer-negotiated fees showed an increasing trend with more complex procedures, ranging from $379.54 (interquartile range [IQR], $230.87-$656.96) for Current Procedural Terminology (CPT) code 12001 ("simple repair of superficial wounds ≤2.5 cm") to $5422.60 ($3983.55-$8169.41) for CPT code 20969 ("free osteocutaneous flap with microvascular anastomosis"). Median percent markup was highest for primary closure procedures (576.17% [IQR, 326.28%-1089.34%]) and lowest for free flaps (99.56% [37.86%-194.02%]). Higher mean percent markups were observed for rural, for-profit, non-Northeast, nonteaching, and smaller hospitals. CONCLUSION Wide variation in private payer-negotiated facility fees exists for head/neck reconstruction surgeries. Further research is necessary to better understand how pricing variation may correlate with out-of-pocket costs and quality of care.
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Affiliation(s)
- Shannon S Wu
- Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vinay K Rathi
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Patrick J Byrne
- Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael A Fritz
- Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio, USA
| | - David A Shaye
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Linda N Lee
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Rosh K V Sethi
- Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Robin W Lindsay
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Roy Xiao
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
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11
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Burney CP, Baumann L, Carlos HA, Briggs A. Impact of Rurality on Geriatric Emergency General Surgery Patients in New Hampshire. J Am Coll Surg 2023; 236:1105-1109. [PMID: 36729798 DOI: 10.1097/xcs.0000000000000501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Geriatric patients requiring emergency general surgery (EGS) have significant risk of morbidity and mortality. Rural patients face decreased access to care. We sought to characterize the EGS needs and impact of rurality for geriatric residents of New Hampshire. STUDY DESIGN A retrospective cohort study of the New Hampshire Uniform Healthcare Facility Discharge Dataset, including patients 65 years and older with urgent/emergent admission who underwent 1 of 7 EGS procedures, grouped by urban or rural county of residence, discharged between 2012-2015. RESULTS New Hampshire has 26 acute care hospitals: 10 (38.5%) are in urban counties and 16 (61.5%) are in rural counties. Thirteen (50.0%) are critical access hospitals (1 urban and 12 rural). Of 2,445 geriatric patient discharges, 40% of patients were from rural counties and were demographically similar to urban patients. Rural patients were more likely to present as a hospital transfer (15.4% vs 2.5%, p < 0.01), receive care at a critical access hospital (24.1% vs 1.0%, p < 0.01), receive care outside their home county (32.5% vs 12.8%, p < 0.01), and be transferred to another hospital after surgery. Rural and urban patients underwent similar procedures, with similar lengths of stay, cost of index hospitalization, and mortality. CONCLUSIONS Rural geriatric patients in New Hampshire are more likely to receive care outside of their home county or be transferred to another hospital. Costs of care were similar but are likely underestimated for rural patients. There was no difference in unadjusted mortality. Further investigation is merited to determine the reasons for hospital transfer in the geriatric EGS population to evaluate which patients may benefit most from remaining close to home vs transferring to other facilities.
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Affiliation(s)
- Charles P Burney
- From the Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Burney, Baumann, Briggs)
- Geisel School of Medicine at Dartmouth, Hanover, NH (Burney, Baumann, Carlos, Briggs)
| | - Laura Baumann
- From the Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Burney, Baumann, Briggs)
- Geisel School of Medicine at Dartmouth, Hanover, NH (Burney, Baumann, Carlos, Briggs)
| | - Heather A Carlos
- Geisel School of Medicine at Dartmouth, Hanover, NH (Burney, Baumann, Carlos, Briggs)
| | - Alexandra Briggs
- From the Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Burney, Baumann, Briggs)
- Geisel School of Medicine at Dartmouth, Hanover, NH (Burney, Baumann, Carlos, Briggs)
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12
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Sridhar S, Mouat-Hunter A, McCrory B. Rural implementation of the perioperative surgical home: A case-control study. World J Orthop 2023; 14:123-135. [PMID: 36998383 PMCID: PMC10044325 DOI: 10.5312/wjo.v14.i3.123] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/01/2023] [Accepted: 02/15/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Perioperative surgical home (PSH) is a novel patient-centric surgical system developed by American Society of Anesthesiologist to improve outcomes and patient satisfaction. PSH has proven success in large urban health centers by reducing surgery cancellation, operating room time, length of stay (LOS), and readmission rates. Yet, only limited studies have assessed the impact of PSH on surgical outcomes in rural areas.
AIM To evaluate the newly implemented PSH system at a community hospital by comparing the surgical outcomes using a longitudinal case-control study.
METHODS The research study was conducted at an 83-bed, licensed level-III trauma rural community hospital. A total of 3096 TJR procedures were collected retrospectively between January 2016 and December 2021 and were categorized as PSH and non-PSH cohorts (n = 2305). To evaluate the importance of PSH in the rural surgical system, a case-control study was performed to compare TJR surgical outcomes (LOS, discharge disposition, and 90-d readmission) of the PSH cohort against two control cohorts [Control-1 PSH (C1-PSH) (n = 1413) and Control-2 PSH (C2-PSH) (n = 892)]. Statistical tests including Chi-square test or Fischer’s exact test were performed for categorical variables and Mann-Whitney test or Student’s t-test were performed for continuous variables. The general linear models (Poisson regression and binomial logistic regression) were performed to fit adjusted models.
RESULTS The LOS was significantly shorter in PSH cohort compared to two control cohorts (median PSH = 34 h, C1-PSH = 53 h, C2-PSH = 35 h) (P value < 0.05). Similarly, the PSH cohort had lower percentages of discharges to other facilities (PSH = 3.5%, C1-PSH = 15.5%, C2-PSH = 6.7%) (P value < 0.05). There was no statistical difference observed in 90-d readmission between control and PSH cohorts. However, the PSH implementation reduced the 90-d readmission percentage (PSH = 4.7%, C1-PSH = 6.1%, C2-PSH = 3.6%) lower than the national average 30-d readmission percentage which is 5.5%. The PSH system was effectively established at the rural community hospital with the help of team-based coordinated multi-disciplinary clinicians or physician co-management. The elements of PSH including preoperative assessment, patient education and optimization, and longitudinal digital engagement were vital for improving the TJR surgical outcomes at the community hospital.
CONCLUSION Implementation of the PSH system in a rural community hospital reduced LOS, increased direct-to-home discharge, and reduced 90-d readmission percentages.
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Affiliation(s)
- Srinivasan Sridhar
- Center for Health Outcomes and Policy Evaluation, College of Public Health, The Ohio State University, Columbus, OH 43210, United States
| | - Amy Mouat-Hunter
- Preanesthesia Clinic, Bozeman Health, Bozeman, MT 59715, United States
| | - Bernadette McCrory
- Mechanical and Industrial Engineering, Montana State University, Bozeman, MT 59715, United States
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13
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A National Evaluation of Emergency General Surgery Outcomes Among Hospitalized Cardiac Patients. J Surg Res 2023; 283:24-32. [PMID: 36368272 DOI: 10.1016/j.jss.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 09/25/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Emergency general surgery among cardiac surgery patients is increasingly common and consequential. We sought to characterize the true burden of emergency general surgery among hospitalized complex cardiac patients. METHODS We performed a retrospective analysis of the 2016-2017 National Inpatient Sample. We included adult patients with a primary diagnosis of complex cardiac disease. We then compared patients who underwent emergency general surgery (GS-OR) with those who did not (non-GS-OR). The primary outcome was mortality; secondary outcomes included length of stay and hospitalization costs. RESULTS We identified 10.2 million patients with a primary diagnosis of complex cardiac disease, of which 148,309 (1.4%) underwent GS-OR. Mortality rates were significantly higher in the GS-OR group (11.0% versus 5.0%, P < 0.001). Among all cardiac patients, GS-OR was associated with 2.2 times increased odds of death (aOR: 2.2, P < 0.001). GS-OR patients also had longer length of stays (14.1 versus 5.8 d, P < 0.001). Among all cardiac patients, GS-OR was associated with an 8.1-day longer length of stay (P < 0.001). GS-OR patients were less often routinely discharged home (31.7% versus 45.3%, P < 0.001) and incurred higher inpatient costs ($46,136 versus $16,303, P < 0.001). Among all cardiac patients, GS-OR patients incurred $30,102 higher hospitalization costs (P < 0.001). CONCLUSIONS Emergency general surgery among cardiac surgery patients is associated with a greater than two-fold increase in mortality, longer length of stays, higher rates of nonroutine discharge, and higher hospitalization costs. Emergency general surgery complications account for 4.0% of total inpatient costs of cardiac surgery patients and merit further study.
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14
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Barthold LK, Burney CP, Baumann LE, Briggs A. Complexity of Transferred Geriatric Adults Requiring Emergency General Surgery: A Rural Tertiary Center Experience. J Surg Res 2023; 283:640-647. [PMID: 36455417 DOI: 10.1016/j.jss.2022.10.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/22/2022] [Accepted: 10/16/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION As the American population ages, the number of geriatric adults requiring emergency general surgery (EGS) care is increasing. EGS regionalization could significantly affect the pattern of care for rural older adults. The aim of this study was to determine the current pattern of care for geriatric EGS patients at our rural academic center, with a focus on transfer status. MATERIALS AND METHODS We performed a retrospective chart review of patients aged ≥65 undergoing EGS procedures within 48 h of admission from 2014 to 2019 at our rural academic medical center. We collected demographic, admission, operative, and outcomes data. The primary outcomes of interest were mortality and nonhome discharge. Univariate and multivariate analyses were performed. RESULTS Over the 5-y study period, 674 patients underwent EGS procedures, with 407 (60%) transferred to our facility. Transfer patients (TPs) had higher American Society of Anesthesiology (ASA) scores (P < 0.001), higher rates of open abdomen (13% versus 5.6%, P = 0.001), and multiple operations (24 versus 11%, P < 0.001) than direct admit patients. However, after adjustment there was no difference in mortality (OR 1.64; 95% CI, 0.82-3.38) or nonhome discharge (OR 1.49; 95% CI, 0.95-2.36). CONCLUSIONS At our institution, the majority of rural geriatric EGS patients were transferred from another hospital for care. These patients had higher medical and operative complexity than patients presenting directly to our facility for care. After adjustment, transfer status was not independently associated with in-hospital mortality or nonhome discharge. These patients were appropriately transferred given their level of complexity.
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Affiliation(s)
- Laura K Barthold
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Charles P Burney
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Laura E Baumann
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Alexandra Briggs
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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15
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Thomas HM, Jarman MP, Mortensen S, Cooper Z, Weaver M, Harris M, Ingalls B, von Keudell A. The role of geographic disparities in outcomes after orthopaedic trauma surgery. Injury 2023; 54:453-460. [PMID: 36414500 DOI: 10.1016/j.injury.2022.11.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 10/10/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Healthcare disparities linked to patient rurality and socioeconomic status are known to exist, but few studies have examined the effect of urban versus rural status on outcomes after orthopedic trauma surgery. The aim of this study was to examine the correlation between patient rurality, socioeconomic status, and outcomes after orthopedic trauma. MATERIALS AND METHODS This is a retrospective cohort study of patients diagnosed with a hip or long bone fracture between January 2016 and December 2017. Data were collected from the Nationwide Inpatient Sample (NIS), a 20% weighted sample of 95% of the U.S. inpatient population. Patients were stratified into 3 groups: isolated hip fracture, isolated long bone fracture, and polytrauma. Bivariate analysis was completed using chi-squared tests for categorical variables and t-tests for continuous variables. Multivariable analysis was completed using population-weighted logistic regression models, based on a conceptual model derived selection of covariates. RESULTS We included 235,393 patients diagnosed with a hip or extremity fracture. These were weighted to represent 1,176,965 patients nationally. In the hip fracture group, rural patient status was associated with higher odds of mortality (OR 1.32, P < 0.001) but not complications (OR 0.95, P = 0.082). In the extremity fracture and polytrauma groups, rural patient status was not associated with significantly higher odds of mortality or complications. In the urban polytrauma group, zip code with below-median income was associated with increased odds of mortality (OR 1.23, P = 0.002) but not complications. In the rural polytrauma group, zip code with below-median income was not associated with significantly increased odds of mortality or complications. In the hip fracture and extremity fracture groups, below-median income was not associated with significantly higher odds of mortality. CONCLUSION We found that rural patients with hip fracture have higher mortality compared to urban patients and that socioeconomic disparities in mortality after a polytrauma exist in urban settings. These results speak to the ongoing need to develop objective measures of disparity-sensitive healthcare and optimize trauma systems to better serve low-income patients and patients in rural areas.
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Affiliation(s)
- Hannah M Thomas
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.
| | - Molly P Jarman
- Center for Surgery and Public Health, Brigham and Women's Hospital, 1620 Tremont St, Boston, MA 02120, USA
| | - Sharri Mortensen
- Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, 1620 Tremont St, Boston, MA 02120, USA; Trauma, Burn and Surgical Care Center, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Michael Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA; Harvard Medical School Orthopaedic Trauma Initiative, 75 Francis St, Boston, MA 02115, USA
| | - Mitchel Harris
- Harvard Medical School Orthopaedic Trauma Initiative, 75 Francis St, Boston, MA 02115, USA; Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Bailey Ingalls
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - Arvind von Keudell
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA; Harvard Medical School Orthopaedic Trauma Initiative, 75 Francis St, Boston, MA 02115, USA
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16
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Li S, Guizzetti L, Ma C, Shaheen AA, Dixon E, Ball C, Wani S, Forbes N. Epidemiology and Outcomes of Symptomatic Cholelithiasis and Cholecystitis in the USA: Trends and Urban-Rural Variations. J Gastrointest Surg 2023; 27:932-944. [PMID: 36720756 DOI: 10.1007/s11605-023-05604-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/29/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Gallstone disease remains a major health issue. There have been significant changes in the management and demographics of patients with these conditions. We aimed to evaluate trends in hospitalization, management, and post-procedural adverse events for patients with gallstone disease. METHODS The National Inpatient Sample was used to identify discharges for symptomatic cholelithiasis and cholecystitis between 2005 and 2014. Temporal trends were evaluated by calculating annual percent changes (APCs). Joinpoint regression was used to assess inflection points. Multivariable regression models were used to evaluate associations between urban and rural divisions and mortality, use of interventional procedures, and post-procedural adverse events. RESULTS From 77,394,755 unweighted discharges, there was a decline in discharges for cholelithiasis (APC - 5.5%, 95% confidence intervals, CI, - 7.6 to - 3.4%) and cholecystitis from 2012 to 2014 (APC - 4.5%, 95% CI - 7.2 to - 1.7%). Interventions were more likely at urban hospitals for symptomatic cholelithiasis (odds ratio, OR, 1.49, 95% CI 1.24 to 1.66) and cholecystitis (OR 1.96, 95% CI 1.86 to 2.05). In-hospital mortality significantly decreased annually for patients with cholecystitis (OR 0.92, 95% CI 0.91 to 0.93). In-hospital mortality between rural and urban centers was comparable for symptomatic cholelithiasis (OR 1.27, 95% CI 0.79 to 2.03) and cholecystitis (OR 0.93, 95% CI 0.84 to 1.04). CONCLUSIONS Hospitalizations for gallstone disease have decreased since the 2010s. In-hospital mortality between urban and rural centers is similar, but urban hospitals utilize a higher rate of procedural interventions. Future studies should evaluate practice trends and costs across inpatient and ambulatory settings between rural and urban divisions.
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Affiliation(s)
- Suqing Li
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, AB, Calgary, Canada.
| | | | - Christopher Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, AB, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Abdel Aziz Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, AB, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Chad Ball
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, AB, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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17
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Christopher AN, Nembhard IM, Wu L, Yee S, Sebastian A, Charan N, Betchen S. Association of women leaders in the C-suite with hospital performance. BMJ LEADER 2022; 6:271-277. [PMID: 36794614 DOI: 10.1136/leader-2021-000543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/28/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Women comprise 50% of the healthcare workforce, but only about 25% of senior leadership positions in the USA. No studies to our knowledge have investigated the performance of hospitals led by women versus those led by men to evaluate the potential explanation that the inequity reflects appropriate selection due to skill or performance differences. METHODS We conducted a descriptive analysis of the gender composition of hospital senior leadership (C-suite) teams and cross-sectional, regression-based analyses of the relationship between gender composition, hospital characteristics (eg, location, size, ownership), and financial, clinical, safety, patient experience and innovation performance metrics using 2018 data for US adult medical/surgical hospitals with >200 beds. C-suite positions examined included chief executive officer (CEO), chief financial officer (CFO) and chief operating officer (COO). Gender was obtained from hospital web pages and LinkedIn. Hospital characteristics and performance were obtained from American Hospital Directory, American Hospital Association Annual Hospital Survey, Healthcare Cost Report Information System and Hospital Consumer Assessment of Healthcare Providers and Systems surveys. RESULTS Of the 526 hospitals studied, 22% had a woman CEO, 26% a woman CFO and 36% a woman COO. While 55% had at least one woman in the C-suite, only 15.6% had more than one. Of the 1362 individuals who held one of the three C-suite positions, 378 were women (27%). Hospital performance on 27 of 28 measures (p>0.05) was similar between women and men-led hospitals. Hospitals with a woman CEO performed significantly better than men-led hospitals on one financial metric, days in accounts receivable (p=0.04). CONCLUSION Hospitals with women in the C-suite have comparable performance to those without, yet inequity in the gender distribution of leaders remains. Barriers to women's advancement should be recognised and efforts made to rectify this inequity, rather than underusing an equally skilled pool of potential women leaders.
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Affiliation(s)
- Adrienne N Christopher
- Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.,Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ingrid M Nembhard
- The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Liza Wu
- Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephanie Yee
- The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Albertina Sebastian
- Division of Neurosurgery, Department of Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Nidhi Charan
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Simone Betchen
- The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA .,Division of Neurosurgery, Department of Surgery, Maimonides Medical Center, Brooklyn, New York, USA
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18
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Bahtigur N, Jeyamohan R, Hamiduzzaman M, Veltre AS. Postoperative complications, length of stay, and mortality following colectomies in rural hospitals: a systematic review and meta-analysis. Postgrad Med 2022; 134:718-731. [PMID: 35984648 DOI: 10.1080/00325481.2022.2115703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Studies regarding patients who have underwent colectomy reported contradictory post-surgical complications based on their living areas. Due to the conflicting data surrounding whether rural or urban hospitals have lower postoperative complication rates, we have performed a systematic review and meta-analysis with the aim of understanding and assessing the evidence that has already been found. METHODS The online databases PubMed, MEDLINE, EMBASE, SCOPUS and CINAHL were searched for our literature review. We included papers with data on the postoperative complication rates for patients who had undergone colectomies. The patients were stratified based on the location status of the hospital, i.e., rural or urban. Data analysis was performed in Cochrane's Review Manager 5.41 software. RESULTS A total of 921 studies were identified in initial search; the inclusion and exclusion criteria refined the search results to 11 studies for review. The primary outcomes analysed were mortality rate, length of stay and total complication rate. This review found that rural hospitals had either equal or lower inpatient postoperative mortality rates in comparison to urban hospitals for patients who had undergone colectomies. However, rural hospitals had a longer length of stay (mean length of stay in rural hospitals was 6.7 days and in urban hospitals was 4.9 days). Important to note that the Australian hospitals had a mean length of stay of 13.5 days, which was almost double that of rural hospitals in America. The unadjusted rate of total complication was 26.51% in rural hospitals. CONCLUSIONS Rural hospitals overall have equivalent postoperative complication rates to urban hospitals and can provide sufficient postoperative patient care.
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Affiliation(s)
- Nazli Bahtigur
- Department of Rural Health, College of Health Medicine & Wellbeing, The University of Newcastle, Australia
| | - Ragavi Jeyamohan
- Department of Rural Health, College of Health Medicine & Wellbeing, The University of Newcastle, Australia
| | - Mohammad Hamiduzzaman
- Department of Rural Health, College of Health Medicine & Wellbeing, The University of Newcastle, Australia.,Faculty of Health, Southern Cross University, Gold Coast, Queensland 4225, Australia
| | - Arron S Veltre
- Manning Education Centre, Department of Rural Health, College of Health Medicine & Wellbeing, The University of Newcastle, Australia
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19
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Kwak MJ, Digbeu BD, des Bordes J, Rianon N. The association of frailty with clinical and economic outcomes among hospitalized older adults with hip fracture surgery. Osteoporos Int 2022; 33:1477-1484. [PMID: 35178610 DOI: 10.1007/s00198-021-06215-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 10/16/2021] [Indexed: 10/19/2022]
Abstract
UNLABELLED Frailty is a common condition among older adults with hip fracture. In our study analyzing National Inpatient Sample data, frailty was found to be associated with up to six times increase in in-patient mortality, 55% increased length of hospital stay, and 29% increase in hospital cost. INTRODUCTION Hip fracture is a significant public health issue posing adverse health outcomes and substantial economic burden to patients and society. Frailty is a prevalent geriatric condition associated with poor clinical outcome among older adults. The association between hip fracture and frailty on both clinical and economic outcomes at the national level has not been estimated. We aimed to determine the association between frailty and in-hospital mortality, length of hospital stay (LOS), and total hospital cost among older patients aged ≥ 65 years who underwent surgery for hip fracture. METHODS We did an analysis of administrative data using the National Inpatient Sample (NIS) data from 2016 and 2017. Our analysis included data on 29,735 hospitalizations. We first conducted a descriptive analysis of the patient characteristics (demographics and clinical) and hospital-related factors. Three multivariable regression analysis models were then used to determine independent associations between frailty and in-hospital mortality, LOS, and total hospital cost. All three models were adjusted for patients' demographic and clinical characteristics and hospital-related factors. RESULTS Moderate and high frailty risk were associated with higher odds of death (OR = 2.94 and 95% CI 1.91-4.51 and OR = 5.99 and 95% CI 3.79-9.47), increased LOS (17% and 55%, p < 0.0001), and higher total hospital cost (7% and 29%, p < 0.0001) respectively compared to low frailty risk. CONCLUSION Frailty was associated with mortality, LOS, and hospital cost after adjusting for patient demographic, clinical, and hospital-related factors. Further research is needed to explore what pre-surgical measures can be assessed to mitigate in-hospital mortality and hospital cost in frail older patients hospitalized for hip fracture surgery.
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Affiliation(s)
- M J Kwak
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | - B D Digbeu
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | - J des Bordes
- Department of Family and Community Medicine, The University of Texas McGovern Medical School, 6431 Fannin St, Suite JJL 324, Houston, TX, 77030, USA
| | - N Rianon
- University of Texas Health Science Center at Houston, Houston, TX, USA.
- Department of Family and Community Medicine, The University of Texas McGovern Medical School, 6431 Fannin St, Suite JJL 324, Houston, TX, 77030, USA.
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20
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Wohlgemut JM, Ramsay G, Bekheit M, Scott NW, Watson AJM, Jansen JO. Emergency general surgery: impact of distance and rurality on mortality. BJS Open 2022; 6:zrac032. [PMID: 35466374 PMCID: PMC9035437 DOI: 10.1093/bjsopen/zrac032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/13/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND There is debate about whether the distance from hospital, or rurality, impacts outcomes in patients admitted under emergency general surgery (EGS). The aim of this study was to determine whether distance from hospital, or rurality, affects the mortality of emergency surgical patients admitted in Scotland. METHODS This was a retrospective population-level cohort study, including all EGS patients in Scotland aged 16 years or older admitted between 1998 and 2018. A multiple logistic regression model was created with inpatient mortality as the dependent variable, and distance from hospital (in quartiles) as the independent variable of interest, adjusting for age, sex, co-morbidity, deprivation, admission origin, diagnosis category, operative category, and year of admission. A second multiple logistic regression model was created with a six-fold Scottish Urban Rural Classification (SURC) as the independent variable of interest. Subgroup analyses evaluated patients who required operations, emergency laparotomy, and inter-hospital transfer. RESULTS Data included 1 572 196 EGS admissions. Those living in the farthest distance quartile from hospital had lower odds of mortality than those in the closest quartile (OR 0.829, 95 per cent c.i. 0.798 to 0.861). Patients from the most rural areas (SURC 6) had higher odds of survival than those from the most urban (SURC 1) areas (OR 0.800, 95 per cent c.i. 0.755 to 0.848). Subgroup analysis showed that these effects were not observed for patients who required emergency laparotomy or transfer. CONCLUSION EGS patients who live some distance from a hospital, or in rural areas, have lower odds of mortality, after adjusting for multiple covariates. Rural and distant patients undergoing emergency laparotomy have no survival advantage, and transferred patients have higher mortality.
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Affiliation(s)
- Jared M. Wohlgemut
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - George Ramsay
- General Surgical Department, Aberdeen Royal Infirmary, Aberdeen, UK
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mohamed Bekheit
- General Surgical Department, Aberdeen Royal Infirmary, Aberdeen, UK
- Department of Surgery, Elkabbary Hospital, Alexandria, Egypt
| | - Neil W. Scott
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | | | - Jan O. Jansen
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Cinaroglu S. Exploring the nexus of equality and efficiency in healthcare. INTERNATIONAL JOURNAL OF PRODUCTIVITY AND PERFORMANCE MANAGEMENT 2022. [DOI: 10.1108/ijppm-04-2021-0221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThis study aims to explore the nexus of equality and efficiency by considering public hospitals' development dynamics, capacity and technology indicators.Design/methodology/approachData was collected from the Ministry of Health Public Hospital Almanacs from 2014 to 2017. The Gini index (GI) is used to estimate the inequality of distribution of hospital performance indicators. A bias-corrected efficiency analysis is calculated to obtain efficiency scores of public hospitals for the year 2017. A path analysis is then constructed to better identify patterns of causation among a set of development, equality and efficiency variables.FindingsA redefined path model highlights that development dynamics, equality and efficiency are causally related and health technology (path coefficient = 0.57; t = 19.07; p < 0.01) and health services utilization (path coefficient = 0.24; t = 8; p < 0.01) effects public hospital efficiency. The final path model fit well (X2/df = 50.99/8 = 6; RMSEA = 0.089; NFI = 0.95; CFI = 0.96; GFI = 0.98; AGFI = 0.94). Study findings indicate high inequalities in distribution of health technologies (GI > 0.85), number of surgical operations (GI > 0.70) and number of inpatients (GI > 0.60) among public hospitals for the years 2014–2017.Originality/valueStudy results highlight that, hospital managers should prioritize equal distribution of health technology and health services utilization indicators to better orchestrate equity-efficiency trade-off in their operations.
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Abstract
BACKGROUND As the United States (US) population increases, the demand for more trauma surgeons (TSs) will increase. There are no recent studies comparing the TS density temporally and geographically. We aim to evaluate the density and distribution of TSs by state and region and its impact on trauma patient mortality. METHODS A retrospective cohort analysis of the American Medical Association Physician Masterfile (PM), 2016 US Census Bureau, and Centers for Disease Control and Prevention (CDC's) Web-based Injury Statistics Query and Reporting System (WISQARS) to determine TS density. TS density was calculated by dividing the number of TSs per 1 000 000 population at the state level, and divided by 500 admissions at the regional level. Trauma-related mortality by state was obtained through the CDC's WISQARS database, which allowed us to estimate trauma mortality per 100 000 population. RESULTS From 2007 to 2014, the net increase of TS was 3160 but only a net increase of 124 TSs from 2014 to 2020. Overall, the US has 12.58 TSs/1 000 000 population. TS density plateaued from 2014 to 2020. 33% of states have a TS density of 6-10/1 000 000 population, 43% have a density of 10-15, 12% have 15-20, and 12% have a density >20. The Northeast has the highest density of TSs per region (2.95/500 admissions), while the Midwest had the lowest (1.93/500 admissions). CONCLUSION The density of TSs in the US varies geographically, has plateaued nationally, and has implications on trauma patient mortality. Future studies should further investigate causes of the TS shortage and implement institutional and educational interventions to properly distribute TSs across the US and reduce geographic disparities.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Carol Sanchez
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Huazhi Liu
- Department of Surgery, 23703Ocala Regional Medical Center, Ocala, FL, USA
- University of Central Florida, Orlando, FL, USA
| | - Darwin Ang
- Department of Surgery, 23703Ocala Regional Medical Center, Ocala, FL, USA
- University of Central Florida, Orlando, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
- University of South Florida, Tampa, FL, USA
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Lu FG, Chen YP, Yang FJ. Do Rural-Urban Identities Affect Individuals’ Health? Evidence From China. INQUIRY: THE JOURNAL OF HEALTH CARE ORGANIZATION, PROVISION, AND FINANCING 2022; 59:469580221104370. [PMID: 35880848 PMCID: PMC9340418 DOI: 10.1177/00469580221104370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We study the relationship between household registration status (Hukou) and the state of individuals’ health to find out whether inequality in health between urban and rural population exists in China. We have used the probit model to regress the state of health on household registration using the individual-level data of the 2018 CFPS survey. We find that inequality in health between urban and rural population does exist in China. Individuals with rural Hukou have a higher probability by 1.4% to be admitted to hospital than individuals with urban Hukou. While, individuals with rural Hukou tend to over-estimate the state of their health as the probability for them to assess themselves healthy is higher by 1.7% than individuals with urban Hukou. The findings suggest that policy makers should recognize the issue of rural-urban health inequalities and take measures, such as controlling pollution in rural areas and providing high quality routine health checks for rural population to deal with the problem.
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Affiliation(s)
- Feng-Gang Lu
- School of Public Administration,
Shandong Technology and Business University, Yantai, Shandong, China
| | - Yin-Ping Chen
- School of Marxism, Shandong Technology
and Business University, Yantai, Shandong, China
- Yin-Ping Chen, East District of Shandong
Technology and Business University, Binhai Middle Road 191#, Laishan District,
Yantai, Shandong, 264005, China.
| | - Fan-Jie Yang
- School of Public Administration,
Shandong Technology and Business University, Yantai, Shandong, China
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Brungardt JG, Almoghrabi OA, Moore CB, Chen GJ, Nagji AS. Rural-Urban Differences in Esophagectomy for Cancer. Kans J Med 2021; 14:292-297. [PMID: 34888000 PMCID: PMC8647987 DOI: 10.17161/kjm.vol14.15597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/24/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Patients who are disadvantaged socioeconomically or live in rural areas may not pursue surgery at high-volume centers where outcomes are better for some complex procedures. The objective of this study was to compare rural and urban patient differences directly by location of residence and outcomes after undergoing esophagectomy for cancer. Methods An analysis of the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) database was performed, capturing adult patients with esophageal cancer who underwent esophagectomy. Patients were stratified into rural or urban groups by the National Center for Health Statistics Urban-Rural Classification Scheme. Demographics, hospital variables, and outcomes were compared. Results A total of 2,877 patients undergoing esophagectomy for esophageal cancer were captured by the database, with 228 (7.92%) rural and 2,575 (89.50%) urban patients. The rural and urban groups had no differences in age, race, and insurance status, and shared many common comorbidities. Major outcomes of mortality (3.95% versus 4.27%, p = 0.815) and length of stay (15.75 ± 13.22 vs. 15.55 ± 14.91 days, p = 0.828) were similar for both rural and urban patients. There was a trend for rural patients to more likely be discharged home (35.96% vs. 29.79%, OR 0.667 [95% CI 0.479 – 0.929]; p = 0.0167). Conclusions This retrospective administrative database study indicated that rural and urban patients received equivalent postoperative care after undergoing esophagectomy. The findings were reassuring as there did not appear to be a disparity in major outcomes depending on the location of residence, but further studies are necessary to assure equitable treatment for rural patients.
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Affiliation(s)
- Joseph G Brungardt
- Department of Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Omar A Almoghrabi
- Department of Cardiothoracic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Carolyn B Moore
- Department of Cardiothoracic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - G John Chen
- Department of Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Alykhan S Nagji
- Department of Cardiothoracic Surgery, University of Kansas Medical Center, Kansas City, KS
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Whitley JA, Kieran K. Geographic Variations in Pharmacy Services and Availability of Commonly Prescribed Pediatric Urology Medications: An Opportunity to Improve Health Equity in Washington State. Urology 2021; 165:285-293. [PMID: 34808141 DOI: 10.1016/j.urology.2021.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/29/2021] [Accepted: 10/13/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe geographic and sociodemographic variations in operating hours and availability of medications commonly prescribed by pediatric urologists at Washington State retail pharmacies. METHODS We identified all retail pharmacies in the state. We stratified counties by population density and household income (HI) and compared differences in pharmacy operating hours and availability of 10 commonly prescribed medications. RESULTS 1057/1058 pharmacies were contacted. All pharmacies had liquid formulations of oxycodone, hydrocodone, ibuprofen, acetaminophen, amoxicillin, and trimethoprim-sulfamethoxazole in stock. Liquid formulations of ciprofloxacin (10%) and oxybutynin (14.3%) were uncommonly stocked, while 92.5% of pharmacies stocked nitrofurantoin suspension, and 80.9% nitrofurantoin capsules. Statewide, 108 (10.2%) of pharmacies were closed on Saturdays and 297 (28.1%) closed on Sunday. More high (HPDC) than low population density (LPDC) (62.5% vs 0%, P < .001) and high-HI than low-HI counties (62.5% vs 0%, P = .30) had 24-hour pharmacies. A larger proportion of pharmacies were open 7-days in HPDC than LPDC (75.6% vs 56.2%, P < .0001) and in high-HI than low-HI counties (100% vs 62.5%, P = .30). The likelihood of a pharmacy being open 7 days/week was significantly higher in HPDC (vs LPDC; OR = 13.2, 95% CI: 4.39-39.7) and high-HI (vs low-HI; OR = 4.98, 95% CI: 2.58-9.60) counties. CONCLUSION Most pharmacies in Washington State carry medications commonly prescribed by pediatric urologists. However, retail pharmacy operating hours are widely variable and create geographic and temporal barriers in rural and poor areas that may limit the timely administration of prescription medication. Providers should consider a patient's practical ability to fill a prescription when starting a time-sensitive medication.
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Affiliation(s)
- Jorge A Whitley
- Division of Urology, Seattle Children's Hospital, Seattle, WA
| | - Kathleen Kieran
- Division of Urology, Seattle Children's Hospital, Seattle, WA; Department of Urology, University of Washington, Seattle, WA.
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Predictive Model for the Assessment of Preoperative Frailty Risk in the Elderly. J Clin Med 2021; 10:jcm10194612. [PMID: 34640630 PMCID: PMC8509404 DOI: 10.3390/jcm10194612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/03/2021] [Accepted: 10/05/2021] [Indexed: 12/21/2022] Open
Abstract
Adequate preoperative evaluation of frailty can greatly assist in the efficient allocation of hospital resources and planning treatments. However, most of the previous frailty evaluation methods, which are complicated, time-consuming, and can have inter-evaluator error, are difficult to apply in urgent situations. Thus, the authors aimed to develop and validate a predictive model for pre-operative frailty risk of elderly patients by using diagnostic and operation codes, which can be obtained easily and quickly from electronic records. We extracted the development cohort of 1762 people who were hospitalized for emergency operations at a single institution between 1 January 2012 and 31 December 2016. The temporal validation cohort from 1 January 2017 to 31 December 2018 in the same center was set. External validation was conducted on 6432 patients aged 75 years or older from 2012 to 2015 who had emergency surgery in the Korean national health insurance database. We developed the Operation Frailty Risk Score (OFRS) by assessing the association of Operation Group and Hospital Frailty Risk Score with the 90-day mortality through logistic regression analysis. We validated the OFRS in both the temporal validation cohort and two external validation cohorts. In the temporal validation cohort and the external validation cohort I and II, the c-statistics for OFRS to predict 90-day mortality were 0.728, 0.626, and 0.619, respectively. OFRS from these diagnostic codes and operation codes may help evaluate the peri-operative frailty risk before emergency surgery for elderly patients where history-taking and pre-operative testing cannot be performed.
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Kornelsen J, Khowaja AR, Av-Gay G, Sullivan E, Parajulee A, Dunnebacke M, Egan D, Balas M, Williamson P. The rural tax: comprehensive out-of-pocket costs associated with patient travel in British Columbia. BMC Health Serv Res 2021; 21:854. [PMID: 34419025 PMCID: PMC8380105 DOI: 10.1186/s12913-021-06833-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 07/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A significant concern for rural patients is the cost of travel outside of their community for specialist and diagnostic care. Often, these costs are transferred to patients and their families, who also experience stress associated with traveling for care. We sought to examine the rural patient experience by (1) estimating and categorizing the various out of pocket costs associated with traveling for healthcare and (2) describing and measuring patient stress and other experiences associated with traveling to seek care, specifically in relation to household income. METHODS We have designed and administered an online, retrospective, cross-sectional survey seeking to estimate the out-of-pocket (OOP) costs and personal experiences of rural patients associated with traveling to access health care in British Columbia. Respondents were surveyed across five categories: Distance Traveled and Transportation Costs, Accommodation Costs, Co-Traveler Costs, Lost Wages, and Patient Stress. Bivariate relationships between respondent household income and other numerical findings were investigated using one-way ANOVA. RESULTS On average, costs for respondents were $856 and $674 for transport and accommodation, respectively. Strong relationships were found to exist between the distance traveled and total transport costs, as well as between a patient's stress and their household income. Patient perspectives obtained from this survey expressed several related issues, including the physical and psychosocial impacts of travel as well as delayed or diminished care seeking. CONCLUSIONS These key findings highlight the existing inequities between rural and urban patient access to health care and how these inequities are exacerbated by a patient's overall travel-distance and financial status. This study can directly inform policy related efforts towards mitigating the rural-urban gap in access to health care.
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Affiliation(s)
- Jude Kornelsen
- Centre for Rural Health Research, Department of Family Practice, University of British Columbia, Suite 320 - 5950 University Blvd, Vancouver, BC, V6T 1Z3, Canada.
| | - Asif Raza Khowaja
- Centre for Rural Health Research, Department of Family Practice, University of British Columbia, Suite 320 - 5950 University Blvd, Vancouver, BC, V6T 1Z3, Canada.,Faculty of Applied Health Sciences, Brock University, Niagara Region, 1812 Sir Isaac Brock Way, St. Catharines, ON, L2S 3A1, Canada
| | - Gal Av-Gay
- Centre for Rural Health Research, Department of Family Practice, University of British Columbia, Suite 320 - 5950 University Blvd, Vancouver, BC, V6T 1Z3, Canada
| | - Eva Sullivan
- Centre for Rural Health Research, Department of Family Practice, University of British Columbia, Suite 320 - 5950 University Blvd, Vancouver, BC, V6T 1Z3, Canada
| | - Anshu Parajulee
- Centre for Rural Health Research, Department of Family Practice, University of British Columbia, Suite 320 - 5950 University Blvd, Vancouver, BC, V6T 1Z3, Canada
| | - Marjorie Dunnebacke
- Centre for Rural Health Research, Department of Family Practice, University of British Columbia, Suite 320 - 5950 University Blvd, Vancouver, BC, V6T 1Z3, Canada
| | - Dorothy Egan
- Centre for Rural Health Research, Department of Family Practice, University of British Columbia, Suite 320 - 5950 University Blvd, Vancouver, BC, V6T 1Z3, Canada
| | - Mickey Balas
- Centre for Rural Health Research, Department of Family Practice, University of British Columbia, Suite 320 - 5950 University Blvd, Vancouver, BC, V6T 1Z3, Canada
| | - Peggy Williamson
- Centre for Rural Health Research, Department of Family Practice, University of British Columbia, Suite 320 - 5950 University Blvd, Vancouver, BC, V6T 1Z3, Canada
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Wan N, McCrum M, Han J, Lizotte S, Su D, Wen M, Zeng S. Measuring spatial access to emergency general surgery services: does the method matter? HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2021. [DOI: 10.1007/s10742-021-00254-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Surgical Diseases are Common and Complicated for Criminal Justice Involved Populations. J Surg Res 2021; 265:27-32. [PMID: 33872846 DOI: 10.1016/j.jss.2021.02.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 01/15/2021] [Accepted: 02/27/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND At any given time, almost 2 million individuals are in prisons or jails in the United States. Incarceration status has been associated with disproportionate rates of cancer and infectious diseases. However, little is known about the burden emergency general surgery (EGS) in criminal justice involved (CJI) populations. MATERIALS AND METHODS The California Office of Statewide Health Planning and Development (OSHPD) database was used to evaluate all hospital admissions with common EGS diagnoses in CJI persons from 2012-2014. The population of CJI individuals in California was determined using United States Bureau of Justice Statistics data. Primary outcomes were rates of admission and procedures for five common EGS diagnoses, while the secondary outcome was probability of complex presentation. RESULTS A total of 4,345 admissions for CJI patients with EGS diagnoses were identified. The largest percentage of EGS admissions were with peptic ulcer disease (41.0%), followed by gallbladder disease (27.5%), small bowel obstruction (14.0%), appendicitis (13.8%), and diverticulitis (10.5%). CJI patients had variable probabilities of receipt of surgery depending on condition, ranging from 6.2% to 90.7%. 5.6% to 21.0% of admissions presented with complicated disease, the highest being with peptic ulcer disease and appendicitis. CONCLUSION Admissions with EGS diagnoses were common and comparable to previously published rates of disease in general population. CJI individuals had high rates of complicated presentation, but low rates of surgical intervention. More granular evaluation of the burden and management of these common, morbid, and costly surgical diagnoses is essential for ensuring timely and quality care delivery for this vulnerable population.
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Urban-Rural Disparities and Temporal Trends in Peptic Ulcer Disease Epidemiology, Treatment, and Outcomes in the United States. Am J Gastroenterol 2021; 116:296-305. [PMID: 33105195 DOI: 10.14309/ajg.0000000000000997] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/16/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The incidence of peptic ulcer disease (PUD) has been decreasing over time with Helicobacter pylori eradication and use of acid-suppressing therapies. However, PUD remains a common cause of hospitalization in the United States. We aimed to evaluate contemporary national trends in the incidence, treatment patterns, and outcomes for PUD-related hospitalizations and compare care delivery by hospital rurality. METHODS Data from the National Inpatient Sample were used to estimate weighted annual rates of PUD-related hospitalizations. Temporal trends were evaluated by joinpoint regression and expressed as annual percent change with 95% confidence intervals (CIs). We determined the proportion of hospitalizations requiring endoscopic and surgical interventions, stratified by clinical presentation and rurality. Multivariable logistic regression was used to assess independent predictors of in-hospital mortality and postoperative morbidity. RESULTS There was a 25.8% reduction (P < 0.001) in PUD-related hospitalizations from 2005 to 2014, although the rate of decline decreased from -7.2% per year (95% CI: 13.2% to -0.7%) before 2008 to -2.1% per year (95% CI: 3.0% to -1.1%) after 2008. In-hospital mortality was 2.4% (95% CI: 2.4%-2.5%). Upper endoscopy (84.3% vs 78.4%, P < 0.001) and endoscopic hemostasis (26.1% vs 16.8%, P < 0.001) were more likely to be performed in urban hospitals, whereas surgery was performed less frequently (9.7% vs 10.5%, P < 0.001). In multivariable logistic regression, patients managed in urban hospitals were at higher risk for postoperative morbidity (odds ratio 1.16 [95% CI: 1.04-1.29]), but not death (odds ratio 1.11 [95% CI: 1.00-1.23]). DISCUSSION The rate of decline in hospitalization rates for PUD has stabilized over time, although there remains significant heterogeneity in treatment patterns by hospital rurality.
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Hospital Location and Socioeconomic Disadvantage of Emergency General Surgery Patients. J Surg Res 2021; 261:376-384. [PMID: 33493890 DOI: 10.1016/j.jss.2020.12.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 11/01/2020] [Accepted: 12/04/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) patients are more socioeconomically vulnerable than elective counterparts. We hypothesized that a hospital's neighborhood disadvantage is associated with vulnerability of its EGS patients. MATERIALS AND METHODS Area deprivation index (ADI), a neighborhood-level measure of disadvantage, and key characteristics of 724 hospitals in 14 states were linked to patient-level data in State Inpatient Databases. Hospital and EGS patient characteristics were compared across hospital ADI quartiles (least disadvantaged [ADI 1-25] "affluent," minimally disadvantaged [ADI 26-50] "min-da", moderately disadvantaged [ADI 51-75] "mod-da", and most disadvantaged [ADI 76-100] "impoverished") using chi2 tests and multivariable regression. RESULTS Higher disadvantage hospitals are more often nonteaching (affluent = 38.9%, min-da = 53.5%, mod-da = 72.1%, and impoverished = 67.6%), nonaffiliated with medical schools (50%, 72.4%, 81.8%, and 78.8%), and in rural areas (3.3%, 9.2%, 31.2%, and 27.9%). EGS patients at higher disadvantage hospitals are more likely to be older (43.9%, 48.6%, 49.1%, and 46.6%), have >3 comorbidities (17.0%, 19.0%, 18.4%, and 19.3%), live in low-income areas (21.4%, 23.6%, 32.2%, and 42.5%), and experience complications (23.2%, 23.7%, 24.0%, and 25.2%). Rates of uninsurance/underinsurance were highest at affluent and impoverished hospitals (18.0, 16.4%, 17.7%, and 19.2%). Higher disadvantage hospitals serve fewer minorities (32.6%, 21.3%, 20.7%, and 24.0%), except in rural areas (2.9%, 6.7%, 6.5%, and 15.5%). In multivariable analyses, the impoverished hospital ADI quartile did not predict odds of serving as a safety-net or predominantly minority-serving hospital. CONCLUSIONS Hospitals in impoverished areas disproportionately serve underserved EGS patient populations but are less likely to have robust resources for EGS care or train future EGS surgeons. These findings have implications for measures to improve equity in EGS outcomes.
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Govind SK, Doumouras AG, Nenshi R, Hong D. Geographic Variation in Appendiceal Perforation Rates in Canada: a Population-Based Cohort Study. J Gastrointest Surg 2020; 24:2620-2627. [PMID: 31792897 DOI: 10.1007/s11605-019-04434-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 10/19/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND We hypothesized that patients living in rural neighborhoods experience delayed access to surgical services manifesting in increased appendiceal perforation rates in cases of appendicitis. METHODS This population-based cohort study included adult patients with acute appendicitis in Canada (excluding Quebec) between April 2008 and March 2015. The main outcome of interest was rate of perforation. Predictors of interest included socioeconomic, geographic, and individual predictors of perforation. Spatial analysis was used to analyze spatial clustering of perforation. RESULTS We identified 143,195 patients throughout the course of the study. The average perforation rate across our study was 35.9% (n = 51,456). Cluster analysis identified 286 (24%) neighborhoods with perforation rates greater than the average. Rural neighborhoods had a 1.89 times higher odds of being in a high perforation cluster (95% CI 1.08-3.08, p = 0.024). Compared to neighborhoods > 75 km from the admitting hospital, closer neighborhoods were less likely to be in a high perforation cluster (0-35 km OR 0.64, 95% CI 0.38-0.98, p = 0.049; 36-75 km OR 0.60, 95% CI 0.37-0.92, p = 0.019). Patients admitted to small community hospitals had a 0.51 times lower odds of perforation than those admitted to academic centers (95% CI 0.47-0.54, p < 0.001) and those who lived in high perforation clusters had a 1.42 times higher odds of perforation (95% CI 1.39-1.46, p < 0.001). CONCLUSION Neighborhoods located far from hospitals have increased appendiceal perforation rates. Also, patients with appendicitis treated at small community hospitals have significantly lower odds of perforation. From a policy point of view, patients with symptoms of appendicitis can be safely treated at the nearest hospital.
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Affiliation(s)
- Shaylan K Govind
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Aristithes G Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Division of General Surgery, Department of Surgery, St. Joseph Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada
| | - Rahima Nenshi
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Division of General Surgery, Department of Surgery, St. Joseph Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada. .,Division of General Surgery, Department of Surgery, St. Joseph Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada.
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Cohen C, Baird M, Koirola N, Kandrack R, Martsolf G. The Surgical and Anesthesia Workforce and Provision of Surgical Services in Rural Communities: A Mixed-Methods Examination. J Rural Health 2020; 37:45-54. [PMID: 32022951 DOI: 10.1111/jrh.12417] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE Rural-urban disparities in the surgical and anesthesia workforce exist. This mixed-methods study describes the distribution of the surgical and anesthesia workforce and qualitatively explores how such workforce and other factors influence rural hospitals' provision of surgical services. METHODS We calculated provider counts by county from the Area Health Resource File. Using American Hospital Association survey data, we sampled rural hospitals, stratified by critical access status and state policies. We conducted qualitative semistructured interviews with administrators at 16 hospitals and performed directed content analysis of factors influencing surgical services provision at rural hospitals. FINDINGS Within rural counties, 55.1% of counties had no surgeon, 81.2% had no anesthesiologist, and 58.1% had no Certified Registered Nurse Anesthetist (CRNA). Administrators reported that rural hospitals struggled to provide many surgical services given lack of subspecialty surgeons and adequate postsurgical care. Rural hospitals likely struggle to generate volumes necessary to support safe and profitable subspecialty surgery programs. Anesthesia services were not reported as a current limitation given that CRNAs in particular had strong, diverse skills sets and many hospitals allowed high CRNA autonomy. However, meeting anesthesia needs for emergency surgeries and 24-hour obstetrics posed significant challenges. CONCLUSIONS While rural hospitals reported meeting community needs for elective and noncomplex surgeries, rural hospitals continued to face significant challenges providing subspecialty surgeries, emergency surgeries, and 24-hour obstetrical services.
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Affiliation(s)
| | | | | | - Ryan Kandrack
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Grant Martsolf
- RAND Corporation, Pittsburgh, Pennsylvania.,Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
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Chaudhary MA, Learn PA, Sturgeon DJ, Havens JM, Goralnick E, Koehlmoos T, Haider AH, Schoenfeld AJ. Emergency General Surgery Volume and Its Impact on Outcomes in Military Treatment Facilities. J Surg Res 2019; 247:287-293. [PMID: 31699538 DOI: 10.1016/j.jss.2019.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/26/2019] [Accepted: 08/14/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Low hospital volume for emergency general surgery (EGS) procedures is associated with worse patient outcomes within the civilian health care system. The military maintains treatment facilities (MTFs) in remote locations to provide access to service members and their families. We sought to determine if patients treated at low-volume MTFs for EGS conditions experience worse outcomes compared with high-volume centers. MATERIALS AND METHODS We analyzed TRICARE data from 2006 to 2014. Patients were identified using an established coding algorithm for EGS admission. MTFs were divided into quartiles based on annual EGS volume. Outcomes included 30-d mortality, complications, and readmissions. Logistic regression models adjusting for clinical and sociodemographic differences in case-mix including EGS condition, surgical intervention, and comorbidities were used to determine the influence of hospital volume on outcomes. RESULTS We identified 106,915 patients treated for an EGS condition at 79 MTFs. The overall mortality rate was 0.21%, with complications occurring in 8.55% and readmissions in 4.45%. After risk adjustment, lowest-volume MTFs did not demonstrate significantly higher odds of mortality (OR: 2.02, CI: 0.45-9.06) or readmissions (OR: 0.77, CI: 0.54-1.11) compared with the highest-volume centers. Lowest-volume facilities exhibited a lower likelihood of complications (OR: 0.76, CI: 0.59-0.98). CONCLUSIONS EGS patients treated at low-volume MTFs did not experience worse clinical outcomes when compared with high-volume centers. Remote MTFs appear to provide care for EGS conditions comparable with that of high-volume facilities. Our findings speak against the need to reduce services at small, critical access facilities within the military health care system.
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Affiliation(s)
- Muhammad Ali Chaudhary
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Peter A Learn
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Daniel J Sturgeon
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joaquim M Havens
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric Goralnick
- Department of Emergency Medicine, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tracey Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Adil H Haider
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Perlstein MD, Gupta S, Ma X, Rong LQ, Askin G, White RS. Abdominal Aortic Aneurysm Repair Readmissions and Disparities of Socioeconomic Status: A Multistate Analysis, 2007-2014. J Cardiothorac Vasc Anesth 2019; 33:2737-2745. [DOI: 10.1053/j.jvca.2019.03.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 01/14/2023]
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de Jager E, Chaudhary MA, Rahim F, Jarman MP, Uribe-Leitz T, Havens JM, Goralnick E, Schoenfeld AJ, Haider AH. The Impact of Income on Emergency General Surgery Outcomes in Urban and Rural Areas. J Surg Res 2019; 245:629-635. [PMID: 31522036 DOI: 10.1016/j.jss.2019.08.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/08/2019] [Accepted: 08/15/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients. MATERIALS AND METHODS The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]). RESULTS 1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P < 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52). CONCLUSIONS Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients.
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Affiliation(s)
- Elzerie de Jager
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; College of Medicine and Dentistry, The James Cook University, Townsville, Queensland, Australia.
| | - Muhammad Ali Chaudhary
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Fatima Rahim
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Molly P Jarman
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tarsicio Uribe-Leitz
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joaquim M Havens
- Division of Trauma Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eric Goralnick
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Adil H Haider
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Tom CM, Friedlander S, Sakai-Bizmark R, Shekherdimian S, Jen H, DeUgarte DA, Lee SL. Outcomes and costs of pediatric appendectomies at rural hospitals. J Pediatr Surg 2019; 54:103-107. [PMID: 30389148 DOI: 10.1016/j.jpedsurg.2018.10.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 10/01/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE Despite policy efforts to support rural hospitals, little is known about the quality and safety of pediatric surgical care in geographically remote areas. Our aim was to determine the outcomes and costs of appendectomies at rural hospitals. METHODS The Kids' Inpatient Database (2003-2012) was queried for appendectomies in children <18 years at urban and rural hospitals. Outcomes (disease severity, laparoscopy, complications, length of stay (LOS), cost) were analyzed with bivariate and multivariable regression analysis. RESULTS Rural hospitals performed 13.6% of appendectomies. On multivariable analysis, rural hospitals were associated with higher negative appendectomy rates (OR 1.49, 95% CI 1.39-1.60, p < 0.001), decreased appendiceal perforation rates (OR 0.86, 95% CI 0.83-0.89, p < 0.001), less laparoscopy use (OR 0.48, 95% CI 0.47-0.50, p < 0.001), higher complication rates (OR 1.29, 95% CI 1.19-1.39, p < 0.001), shorter LOS (IRR 0.90, 95% CI 0.89-0.91, p < 0.001), and slightly increased costs (exponentiated log$ 1.02, 95% CI 1.01-1.02, p < 0.001) CONCLUSIONS: Rural hospitals care for fewer patients with advanced appendicitis but are associated with higher negative appendectomy rates, lower laparoscopy use, and higher complication rates. Additional studies are needed to identify factors that drive this disparity to improve the quality of pediatric surgical care in rural settings. TYPE OF STUDY Treatment/Cost Study (Outcomes). LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Cynthia M Tom
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA
| | - Scott Friedlander
- Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA 90502, USA
| | - Rie Sakai-Bizmark
- Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA 90502, USA
| | - Shant Shekherdimian
- Division of Pediatric Surgery, UCLA, 10833 Le Conte Ave, Box 709818, Los Angeles, CA 90095, USA
| | - Howard Jen
- Division of Pediatric Surgery, UCLA, 10833 Le Conte Ave, Box 709818, Los Angeles, CA 90095, USA
| | - Daniel A DeUgarte
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA 90502, USA; Division of Pediatric Surgery, UCLA, 10833 Le Conte Ave, Box 709818, Los Angeles, CA 90095, USA
| | - Steven L Lee
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA 90502, USA; Division of Pediatric Surgery, UCLA, 10833 Le Conte Ave, Box 709818, Los Angeles, CA 90095, USA.
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Tom CM, Howell EC, Won RP, Friedlander S, Sakai-Bizmark R, de Virgilio C, Lee SL. Assessing outcomes and costs of appendectomies performed at rural hospitals. Am J Surg 2018; 217:1102-1106. [PMID: 30389118 DOI: 10.1016/j.amjsurg.2018.10.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 10/18/2018] [Accepted: 10/26/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of our study was to assess the outcomes and costs of appendectomies performed at rural and urban hospitals. METHODS The National Inpatient Sample (2001-2012) was queried for appendectomies at urban and rural hospitals. Outcomes (disease severity, laparoscopy, complications, length of stay (LOS), and cost) were analyzed. RESULTS Rural patients were more likely to be older, male, white, and have Medicaid or no insurance. Rural hospitals were associated with higher negative appendectomy rates (OR = 1.26,95%CI = 1.18-1.34,p < 0.01), less laparoscopy use (OR = 0.65,95%CI = 0.58-0.72,p < 0.01), and slightly shorter LOS (OR = 0.98,95%CI = 0.97-0.99,p < 0.01). There was no consistent association with perforated appendicitis and no difference in complications or costs after adjusting for hospital volume. Yearly trends showed a significant increase in the cases utilizing laparoscopy each year at rural hospitals. CONCLUSIONS Rural appendectomies are associated with increased negative appendectomy rates and less laparoscopy use with no difference in complications or costs compared to urban hospitals.
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Affiliation(s)
- Cynthia M Tom
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA
| | - Erin C Howell
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA
| | - Roy P Won
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA
| | - Scott Friedlander
- Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA, 90502, USA
| | - Rie Sakai-Bizmark
- Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA, 90502, USA
| | - Christian de Virgilio
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA, 90502, USA
| | - Steven L Lee
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA; Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA, 90502, USA.
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Chaudhary MA, Jiang W, Lipsitz S, Hashmi ZG, Koehlmoos TP, Learn P, Haider AH, Schoenfeld AJ. The Transition to Data-Driven Quality Metrics: Determining the Optimal Surveillance Period for Complications After Surgery. J Surg Res 2018; 232:332-337. [PMID: 30463738 DOI: 10.1016/j.jss.2018.06.059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/08/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Thirty-day complications frequently serve in the surgical literature as a quality indicator. This metric is not meant to capture the full array of complication resulting from surgical intervention. However, this period is largely based on convention, with little evidence to support it. This study sought to determine the optimal surveillance period for postsurgical complications, defined as the shortest period that also encompassed the highest proportion of postsurgical adverse events. METHODS TRICARE data (2006-2014) were queried for adult (18-64 y) patients who underwent one of 11 surgical procedures. Patients were assessed for complications up to 90 d after surgery. Kaplan-Meier curves, linear spline regression models at each incremental postsurgical day, and adjusted R-squared values were used to identify critical time point cutoffs for the surveillance of complications. Optimal length of surveillance was defined as the postsurgical day on which the model demonstrated the highest R-squared value. A supplemental analysis considered these measures for orthopedic and general surgical procedures. RESULTS One lakh ninety-eight patients met the inclusion criteria. A total of 21.8% patients experienced at least one complication during the follow-up period, with 59% occurring within the first 15 d. Kaplan-Meier curves for complications showed a demonstrable inflection before 20 d and 14-15 d possessed the highest R-squared values. CONCLUSIONS In this analysis, the optimal surveillance period for postsurgical complications was 15 d. While the conventional 30-d period may still be appropriate for a variety of reasons, the shorter interval identified here may represent a superior quality measure specific to surgical practice.
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Affiliation(s)
- Muhammad Ali Chaudhary
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Wei Jiang
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stuart Lipsitz
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zain G Hashmi
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Peter Learn
- Uniformed Services University, Bethesda, Maryland
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Ameratunga S, Ramke J, Jackson N, Tin Tin S, Gabbe B. Disparities in Non-Fatal Health Outcomes in Pediatric General Trauma Studies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 15:ijerph15010043. [PMID: 29280986 PMCID: PMC5800142 DOI: 10.3390/ijerph15010043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/21/2017] [Accepted: 12/25/2017] [Indexed: 12/01/2022]
Abstract
When prevention efforts fail, injured children require high-quality health services to support their recovery. Disparities in non-fatal injury outcomes, an indicator of health-care quality, have received minimal attention. We evaluated the extent to which general trauma follow-up studies published in the peer-reviewed scientific literature provide evidence of socially patterned inequities in health, functional or disability outcomes ≥4 weeks after childhood injuries. Using a systematic search, we identified 27 eligible cohort studies from 13 high-income countries. We examined the extent to which the reported health outcomes varied across the PROGRESS criteria: place of residence, race/ethnicity, occupation, gender/sex, religion, socio-economic status, and social capital. The available evidence on differential outcomes is limited as many studies were compromised by selection or retention biases that reduced the participation of children from demographic groups at increased risk of adverse outcomes, or the analyses mainly focused on variations in outcomes by sex. Given the limited research evidence, we recommend greater attention to systematic collection and reporting of non-fatal injury outcomes disaggregated by socio-demographic indicators in order to identify disparities where these exist and inform equity-focused interventions promoting the recovery of injured children.
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Affiliation(s)
- Shanthi Ameratunga
- Epidemiology and Biostatistics, School of Population Health, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Jacqueline Ramke
- Epidemiology and Biostatistics, School of Population Health, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Nicki Jackson
- Alcohol Healthwatch, Office Park Building Level 1, 27 Gillies Ave, Auckland 1023, New Zealand.
| | - Sandar Tin Tin
- Epidemiology and Biostatistics, School of Population Health, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Belinda Gabbe
- Department of Epidemiology and Preventive Medicine, Monash University, School of Public Health and Preventive Medicine, Level 3, 553 St Kilda Road, Melbourne 3004, Australia.
- Farr Institute, Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK.
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