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Branche C, Sakowitz S, Porter G, Cho NY, Chervu N, Mallick S, Bakhtiyar SS, Benharash P. Utilization of minimally invasive colectomy at safety-net hospitals in the United States. Surgery 2024:S0039-6060(24)00201-0. [PMID: 38729887 DOI: 10.1016/j.surg.2024.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/17/2024] [Accepted: 03/21/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Prior literature has reported inferior surgical outcomes and reduced access to minimally invasive procedures at safety-net hospitals. However, this relationship has not yet been elucidated for elective colectomy. We sought to characterize the association between safety-net hospitals and likelihood of minimally invasive resection, perioperative outcomes, and costs. METHODS All adult (≥18 years) hospitalization records entailing elective colectomy were identified in the 2016-2020 National Inpatient Sample. Centers in the top quartile of safety-net burden were considered safety-net hospitals (others: non-safety-net hospitals). Multivariable regression models were developed to assess the impact of safety-net hospitals status on key outcomes. RESULTS Of ∼532,640 patients, 95,570 (17.9%) were treated at safety-net hospitals. The safety-net hospitals cohort was younger and more often of Black race or Hispanic ethnicity. After adjustment, care at safety-net hospitals remained independently associated with reduced odds of minimally invasive surgery (adjusted odds ratio 0.92; 95% confidence interval 0.87-0.97). The interaction between safety-net hospital status and race was significant, such that Black race remained linked with lower odds of minimally invasive surgery at safety-net hospitals (reference: White race). Additionally, safety-net hospitals was associated with greater likelihood of in-hospital mortality (adjusted odds ratio 1.34, confidence interval 1.04-1.74) and any perioperative complication (adjusted odds ratio 1.15, confidence interval 1.08-1.22), as well as increased length of stay (β+0.26 days, confidence interval 0.17-0.35) and costs (β+$2,510, confidence interval 2,020-3,000). CONCLUSION Care at safety-net hospitals was linked with lower odds of minimally invasive colectomy, as well as greater complications and costs. Black patients treated at safety-net hospitals demonstrated reduced likelihood of minimally invasive surgery, relative to White patients. Further investigation is needed to elucidate the root causes of these disparities in care.
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Affiliation(s)
- Corynn Branche
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Stanford University, Palo Alto, CA. https://twitter.com/CoreLabUCLA
| | - Sara Sakowitz
- CORELAB, Department of Surgery, University of California, Los Angeles, CA. https://twitter.com/sarasakowitz
| | - Giselle Porter
- CORELAB, Department of Surgery, University of California, Los Angeles, CA
| | - Nam Yong Cho
- CORELAB, Department of Surgery, University of California, Los Angeles, CA
| | - Nikhil Chervu
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA
| | - Saad Mallick
- CORELAB, Department of Surgery, University of California, Los Angeles, CA
| | - Syed Shahyan Bakhtiyar
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO
| | - Peyman Benharash
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA.
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Dai J, Guo Y, Zhou Q, Duan XJ, Shen J, Zhang X. The relationship between red cell distribution width, serum calcium ratio, and in-hospital mortality among patients with acute respiratory failure: A retrospective cohort study of the MIMIC-IV database. Medicine (Baltimore) 2024; 103:e37804. [PMID: 38608105 PMCID: PMC11018187 DOI: 10.1097/md.0000000000037804] [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: 11/13/2023] [Accepted: 03/14/2024] [Indexed: 04/14/2024] Open
Abstract
To investigate the impact of RDW/CA (the ratio of red cell distribution width to calcium) on in-hospital mortality in patients with acute respiratory failure (ARF). This retrospective cohort study analyzed the data of 6981 ARF patients from the Medical Information Mart for Intensive Care (MIMIC-IV) database 2.0. Critically ill participants between 2008 and 2019 at the Beth Israel Deaconess Medical Center in Boston. The primary outcome of interest was in-hospital mortality. A Cox proportional hazards regression model was used to determine whether the RDW/CA ratio independently correlated with in-hospital mortality. The Kaplan-Meier method was used to plot the survival curves of the RDW/CA. Subgroup analyses were performed to measure the mortality across various subgroups. After adjusting for potential covariates, we found that a higher RDW/CA was associated with an increased risk of in-hospital mortality (HR = 1.17, 95% CI: 1.01-1.35, P = .0365) in ARF patients. A nonlinear relationship was observed between RDW/CA and in-hospital mortality, with an inflection point of 1.97. When RDW/CA ≥ 1.97 was positively correlated with in-hospital mortality in patients with ARF (HR = 1.554, 95% CI: 1.183-2.042, P = .0015). The Kaplan-Meier curve indicated the higher survival rates for RDW/CA < 1.97 and the lower for RDW/CA ≥ 1.97 after adjustment for age, gender, body mass index, and ethnicity. RDW/CA is an independent predictor of in-hospital mortality in patients with ARF. Furthermore, a nonlinear relationship was observed between RDW/CA and in-hospital mortality in patients with ARF.
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Affiliation(s)
- Jun Dai
- Department of Nursing, The First People’s Hospital of Changde City, Changde, Hunan Province, China
| | - Yafen Guo
- Department of Nursing, The First People’s Hospital of Changde City, Changde, Hunan Province, China
| | - Quan Zhou
- Department of Science and Education, The First People’s Hospital of Changde City, Changde, Hunan Province, China
| | - Xiang-Jie Duan
- Department of Infectious Diseases, The First People’s Hospital of Changde City, Changde, Hunan Province, China
| | - Jinhua Shen
- Department of Nursing, The First People’s Hospital of Changde City, Changde, Hunan Province, China
| | - Xueqing Zhang
- Department of Nursing, The First People’s Hospital of Changde City, Changde, Hunan Province, China
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Kopanczyk R, Lisco SJ, Pearl R, Demiralp G, Naik BI, Mazzeffi MA. Racial and Ethnic Disparities in Veno-Venous Extracorporeal Membrane Oxygenation Mortality for Patients With Severe COVID-19. ASAIO J 2024; 70:62-67. [PMID: 37815999 DOI: 10.1097/mat.0000000000002072] [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: 10/12/2023] Open
Abstract
Racial/ethnic disparities in mortality were observed during the coronavirus disease-2019 pandemic, but investigations examining the association between race/ethnicity and mortality during extracorporeal membrane oxygenation (ECMO) are limited. We performed a retrospective observational cohort study using the 2020 national inpatient sample. Multivariable logistic regression was used to estimate the odds of mortality in patients of difference race/ethnicity while controlling for confounders. There was a significant association between race/ethnicity and in-hospital mortality ( p < 0.001). Hispanic patients had significantly higher in-hospital mortality compared with White patients (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.16-1.67, p < 0.001). Black patients and patients of other races did not have significantly higher in-hospital mortality compared with White patients (OR = 0.82, 95% CI = 0.66-1.02, p = 0.07 and OR = 1.20, 95% CI = 0.92-1.57, p = 0.18). Other variables that had a significant association with mortality included age, insurance type, Charlson comorbidity index, all patient-refined severity of illness, and receipt of care in a low-volume ECMO center (all p < 0.001). Further studies are needed to understand causes of disparities in ECMO mortality.
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Affiliation(s)
- Rafal Kopanczyk
- From the Division of Critical Care, Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Steven J Lisco
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ronald Pearl
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, California
| | - Gozde Demiralp
- Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin
| | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
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Blank JA, Armstrong-Hough M, Valley TS. Disparities among patients with respiratory failure. Curr Opin Crit Care 2023; 29:493-504. [PMID: 37641499 PMCID: PMC10599128 DOI: 10.1097/mcc.0000000000001079] [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] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Disparities are common within healthcare, and critical illness is no exception. This review summarizes recent literature on health disparities within respiratory failure, focusing on race, ethnicity, socioeconomic status, and sex. RECENT FINDINGS Current evidence indicates that Black patients have higher incidence of respiratory failure, while the relationships among race, ethnicity, and mortality remains unclear. There has been renewed interest in medical device bias, specifically pulse oximetry, for which data demonstrate patients with darker skin tones may be at risk for undetected hypoxemia and worse outcomes. Lower socioeconomic status is associated with higher mortality, and respiratory failure can potentiate socioeconomic inequities via illness-related financial toxicity. Literature on sex-based disparities is limited; however, evidence suggests males receive more invasive care, including mechanical ventilation. SUMMARY Most studies focused on disparities in incidence and mortality associated with respiratory failure, but few relied on granular clinical data of patients from diverse backgrounds. Future studies should evaluate processes of care for respiratory failure that may mechanistically contribute to disparities in order to develop interventions that improve outcomes.
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Affiliation(s)
| | - Mari Armstrong-Hough
- New York University School of Global Public Health, Department of Social & Behavioral Sciences, Department of Epidemiology
| | - Thomas S. Valley
- University of Michigan, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan
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Lyu G, Nakayama M. Prediction of respiratory failure risk in patients with pneumonia in the ICU using ensemble learning models. PLoS One 2023; 18:e0291711. [PMID: 37733699 PMCID: PMC10513189 DOI: 10.1371/journal.pone.0291711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/04/2023] [Indexed: 09/23/2023] Open
Abstract
The aim of this study was to develop early prediction models for respiratory failure risk in patients with severe pneumonia using four ensemble learning algorithms: LightGBM, XGBoost, CatBoost, and random forest, and to compare the predictive performance of each model. In this study, we used the eICU Collaborative Research Database (eICU-CRD) for sample extraction, built a respiratory failure risk prediction model for patients with severe pneumonia based on four ensemble learning algorithms, and developed compact models corresponding to the four complete models to improve clinical practicality. The average area under receiver operating curve (AUROC) of the models on the test sets after ten random divisions of the dataset and the average accuracy at the best threshold were used as the evaluation metrics of the model performance. Finally, feature importance and Shapley additive explanation values were introduced to improve the interpretability of the model. A total of 1676 patients with pneumonia were analyzed in this study, of whom 297 developed respiratory failure one hour after admission to the intensive care unit (ICU). Both complete and compact CatBoost models had the highest average AUROC (0.858 and 0.857, respectively). The average accuracies at the best threshold were 75.19% and 77.33%, respectively. According to the feature importance bars and summary plot of the predictor variables, activetx (indicates whether the patient received active treatment), standard deviation of prothrombin time-international normalized ratio, Glasgow Coma Scale verbal score, age, and minimum oxygen saturation and respiratory rate were important. Compared with other ensemble learning models, the complete and compact CatBoost models have significantly higher average area under the curve values on the 10 randomly divided test sets. Additionally, the standard deviation (SD) of the compact CatBoost model is relatively small (SD:0.050), indicating that the performance of the compact CatBoost model is stable among these four ensemble learning models. The machine learning predictive models built in this study will help in early prediction and intervention of respiratory failure risk in patients with pneumonia in the ICU.
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Affiliation(s)
- Guanqi Lyu
- Department of Medical Informatics, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Masaharu Nakayama
- Department of Medical Informatics, Tohoku University Graduate School of Medicine, Miyagi, Japan
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Sakowitz S, Mabeza RM, Bakhtiyar SS, Verma A, Ebrahimian S, Vadlakonda A, Revels S, Benharash P. Acute clinical and financial outcomes of esophagectomy at safety-net hospitals in the United States. PLoS One 2023; 18:e0285502. [PMID: 37224136 DOI: 10.1371/journal.pone.0285502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/25/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND While safety-net hospitals (SNH) play a critical role in the care of underserved communities, they have been associated with inferior postoperative outcomes. This study evaluated the association of hospital safety-net status with clinical and financial outcomes following esophagectomy. METHODS All adults (≥18 years) undergoing elective esophagectomy for benign and malignant gastroesophageal disease were identified in the 2010-2019 Nationwide Readmissions Database. Centers in the highest quartile for the proportion of uninsured/Medicaid patients were classified as SNH (others: non-SNH). Regression models were developed to evaluate adjusted associations between SNH status and outcomes, including in-hospital mortality, perioperative complications, and resource use. Royston-Parmar flexible parametric models were used to assess time-varying hazard of non-elective readmission over 90 days. RESULTS Of an estimated 51,649 esophagectomy hospitalizations, 9,024 (17.4%) were performed at SNH. While SNH patients less frequently suffered from gastroesophageal malignancies (73.2 vs 79.6%, p<0.001) compared to non-SNH, the distribution of age and comorbidities were similar. SNH was independently associated with mortality (AOR 1.24, 95% CI 1.03-1.50), intraoperative complications (AOR 1.45, 95% CI 1.20-1.74) and need for blood transfusions (AOR 1.61, 95% CI 1.35-1.93). Management at SNH was also associated with incremental increases in LOS (+1.37, 95% CI 0.64-2.10), costs (+10,400, 95% CI 6,900-14,000), and odds of 90-day non-elective readmission (AOR 1.11, 95% CI 1.00-1.23). CONCLUSIONS Care at safety-net hospitals was associated with higher odds of in-hospital mortality, perioperative complications, and non-elective rehospitalization following elective esophagectomy. Efforts to provide sufficient resources at SNH may serve to reduce complications and overall costs for this procedure.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Russyan Mark Mabeza
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
- Department of Surgery, University of Colorado, Aurora, CO, United States of America
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Shayan Ebrahimian
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Sha'shonda Revels
- Department of Surgery, University of California, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
- Department of Surgery, University of California, Los Angeles, CA, United States of America
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Sakowitz S, Verma A, Mabeza RM, Cho NY, Hadaya J, Toste P, Benharash P. Clinical and financial outcomes of pulmonary resection for lung cancer in safety-net hospitals. J Thorac Cardiovasc Surg 2023; 165:1577-1584.e1. [PMID: 36328819 DOI: 10.1016/j.jtcvs.2022.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/02/2022] [Accepted: 09/07/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Safety-net hospitals (SNHs) have previously been associated with inferior outcomes and greater resource use. However, this relationship has not been explored in the contemporary setting of pulmonary lobectomy. In the present national study we characterized the association between SNHs and mortality, complications, and resource use. METHODS All adults (18 years of age or older) who underwent elective lobectomy for lung cancer were identified within the 2010 to 2019 Nationwide Readmissions Database. Hospitals in the highest quartile of safety-net burden were categorized as SNHs, and others non-SNHs. Multivariable regressions were developed to assess the independent association between safety-net status and outcomes of interest. RESULTS Of an estimated 282,011 patients who met inclusion criteria, 41,015 (14.5%) were treated at SNHs. Patients at SNHs were younger but as commonly female, compared with non-SNHs. After multivariable adjustment, there was no association between SNHs and mortality. However, treatment at SNHs was linked to higher odds of pneumonia (adjusted odds ratio [AOR], 1.11; 95% CI, 1.02-1.21) and prolonged ventilation (AOR, 1.36; 95% CI, 1.11-1.66), as well as infectious (AOR, 1.24; 95% CI, 1.08-1.43), intraoperative (AOR, 1.22; 95% CI, 1.07-1.39), and overall complications (AOR, 1.07; 95% CI, 1.01-1.14). Patients at SNHs also showed a greater need for a blood transfusion (AOR, 1.37; 95% CI, 1.23-1.53). In addition, SNHs were associated with increased length of stay (+0.33 days; 95% CI, 0.17-0.48) and greater costs (+$4130; 95% CI, 3.34-4.92), relative to non-SNHs. CONCLUSIONS Hospital safety-net status was associated with greater odds of perioperative complications and greater health care expenditure. Further investigation is necessary uncover the mechanisms contributing to these complications and eradicate persistent disparities in lobectomy.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Russyan Mark Mabeza
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Paul Toste
- Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, Calif; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, Calif.
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Williamson CG, Park MG, Mooney B, Mantha A, Verma A, Benharash P. Insurance-Based Disparities in Congenital Cardiac Operations in the Era of the Affordable Care Act. Pediatr Cardiol 2023; 44:826-835. [PMID: 36906870 PMCID: PMC10063518 DOI: 10.1007/s00246-023-03136-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/25/2023] [Indexed: 03/13/2023]
Abstract
A body of literature has previously highlighted the impact of health insurance on observed disparities in congenital cardiac operations. With aims of improving access to healthcare for all patients, the Affordable Care Act (ACA) expanded Medicaid coverage to nearly all eligible children in 2010. Therefore, the present population-based study aimed to examine the association of Medicaid coverage with clinical and financial outcomes in the era the ACA. Records for pediatric patients (≤ 18 years) who underwent congenital cardiac operations were abstracted from the 2010-2018 Nationwide Readmissions Database. Operations were stratified using the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Category. Multivariable regression models were developed to evaluate the association of insurance status on index mortality, 30-day readmissions, care fragmentation, and cumulative costs. Of an estimated 132,745 hospitalizations for congenital cardiac surgery from 2010 to 2018, 74,925 (56.4%) were insured by Medicaid. The proportion of Medicaid patients increased from 57.6 to 60.8% during the study period. On adjusted analysis, patients with Medicaid insurance were at an increased odds of mortality (1.35, 95%CI: 1.13-1.60) and 30-day unplanned readmission (1.12, 95%CI: 1.01-1.25), experienced longer lengths of stay (+ 6.5 days, 95%CI 3.7-9.3), and exhibited higher cumulative hospitalization costs (+ $21,600, 95%CI: $11,500-31,700). The total hospitalization cost-burden for patients with Medicaid and private insurance were $12.6 billion and $8.06 billion, respectively. Medicaid patients exhibited increased mortality, readmissions, care fragmentation, and costs compared to those with private insurance. Our results of outcome variation by insurance status indicate the necessity of policy changes to attempt to approach equality in surgical out comes for this high-risk cohort. Baseline characteristics, trends, and outcomes by insurance status over the ACA rollout period 2010-2018.
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Affiliation(s)
- Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 64-249 CHS, Los Angeles, CA, 90095, USA
| | - Mina G Park
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 64-249 CHS, Los Angeles, CA, 90095, USA
| | - Bailey Mooney
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 64-249 CHS, Los Angeles, CA, 90095, USA
| | - Aditya Mantha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 64-249 CHS, Los Angeles, CA, 90095, USA.,Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 64-249 CHS, Los Angeles, CA, 90095, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 64-249 CHS, Los Angeles, CA, 90095, USA.
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Impact of Hospital Safety-Net Burden on Outcomes of In-Hospital Cardiac Arrest in the United States. Crit Care Explor 2023; 5:e0838. [PMID: 36699243 PMCID: PMC9831170 DOI: 10.1097/cce.0000000000000838] [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] [Indexed: 01/27/2023] Open
Abstract
High safety-net burden hospitals (HBHs) treating large numbers of uninsured or Medicaid-insured patients have generally been linked to worse clinical outcomes. However, limited data exist on the impact of the hospitals' safety-net burden on in-hospital cardiac arrest (IHCA) outcomes in the United States. OBJECTIVES To compare the differences in survival to discharge, routine discharge home, and healthcare resource utilization between patients at HBH with those treated at low safety-net burden hospital (LBH). DESIGN SETTING AND PARTICIPANTS Retrospective cohort study across hospitals in the United States: Hospitalized patients greater than or equal to 18 years that underwent cardiopulmonary resuscitation (CPR) between 2008 and 2018 identified from the Nationwide Inpatient Database. Data analysis was conducted in January 2022. EXPOSURE IHCA. MAIN OUTCOMES AND MEASURES The primary outcome is survival to hospital discharge. Other outcomes are routine discharge home among survivors, length of hospital stay, and total hospitalization cost. RESULTS From 2008 to 2018, an estimated 555,016 patients were hospitalized with IHCA, of which 19.2% occurred at LBH and 55.2% at HBH. Compared with LBH, patients at HBH were younger (62 ± 20 yr vs 67 ± 17 yr) and predominantly in the lowest median household income (< 25th percentile). In multivariate analysis, HBH was associated with lower chances of survival to hospital discharge (adjusted odds ratio [aOR], 0.88; 95% CI, 0.85-0.96) and lower odds of routine discharge (aOR, 0.6; 95% CI, 0.47-0.75), compared with LBH. In addition, IHCA patients at publicly owned hospitals and those with medium and large hospital bed size were less likely to survive to hospital discharge, while patients with median household income greater than 25th percentile had better odds of hospital survival. CONCLUSIONS AND RELEVANCE Our study suggests that patients who experience IHCA at HBH may have lower rates and odds of in-hospital survival and are less likely to be routinely discharged home after CPR. Median household income and hospital-level characteristics appear to contribute to survival.
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Sakowitz S, Ng A, Williamson CG, Verma A, Hadaya J, Khoraminejad B, Benharash P. Impact of inter-hospital transfer on outcomes of urgent cholecystectomy. Am J Surg 2023; 225:107-112. [PMID: 36182598 DOI: 10.1016/j.amjsurg.2022.09.035] [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: 04/16/2022] [Revised: 06/29/2022] [Accepted: 09/18/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND This study used a national cohort to characterize the impact of inter-hospital transfer status on outcomes following nonelective cholecystectomy for cholecystitis. METHODS Nonelective cholecystectomies were identified using the 2016-2019 National Inpatient Sample. Multivariable models adjusting for patient and hospital characteristics were utilized to assess outcomes of interest. RESULTS Of an estimated 530,696 patients, 5.3% were transferred. Transferred patients were older, more often male, and more likely to report income in the 0th-25th percentile, compared to others. After adjustment, transfer was associated with increased odds of infectious complications (AOR 1.31, 95%CI 1.06-1.60) and non-home discharge (AOR 1.59, 95%CI 1.45-1.74), but not mortality. Transfer was linked to a $600 cost decrement at the operating hospital (95%CI -$880-330). CONCLUSIONS Transfer status is associated with greater postoperative infection, but not mortality. Given that disparities may play a role in transfer decisions, more work must be done to identify transfer drivers and improve patient outcomes.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ayesha Ng
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Baran Khoraminejad
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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11
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Kim ST, Tran Z, Xia Y, Dobaria V, Ng A, Benharash P. Utilization of mechanical prostheses and outcomes of surgical aortic valve replacement at safety net hospitals. Surg Open Sci 2022; 9:28-33. [PMID: 35620708 PMCID: PMC9127193 DOI: 10.1016/j.sopen.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/28/2022] [Accepted: 04/10/2022] [Indexed: 11/26/2022] Open
Abstract
Background Safety-net hospitals care for a high proportion of uninsured/underinsured patients who may lack access to longitudinal care. The present study characterized the use of mechanical valves and clinical outcomes of surgical aortic valve replacement at safety net hospitals. Methods All adults undergoing surgical aortic valve replacement were abstracted from the 2016–2018 Nationwide Readmissions Database. Hospitals were divided into quartiles based on volume of all Medicaid and uninsured admissions, with the highest quartile defined as safety net hospitals. Multivariable regression was used to determine the association between safety net hospitals and several outcomes including mechanical valve use, perioperative complications, index hospitalization costs, 90-day readmission, and complications at readmission. Results Of the 94,580 patients undergoing surgical aortic valve replacement, 14.5% of operations were at safety net hospitals. Patients at safety net hospitals more commonly received mechanical valves (20.3% vs 16.9%, P < .01) compared to those at non–safety net hospitals. After adjustment, safety net hospitals remained associated with a greater odds of mechanical aortic valve use (adjusted odds ratio, 1.13, 95% confidence interval 1.05–1.21). However, operation at safety net hospitals was also associated with increased odds of perioperative complications (adjusted odds ratio 1.10, 95% confidence interval 1.03–1.17) and higher hospitalization costs (β coefficient +$6.15K, 95% confidence interval +$5.26 − +$7.03) despite similar 90-day readmissions. Upon readmission, safety net hospitals patients were more likely to experience mortality (adjusted odds ratio 1.87, 95% confidence interval 1.18–2.98) and stroke (adjusted odds ratio 2.41, 95% confidence interval 1.23–4.70) compared to those at non–safety net hospitals. Conclusion Hospital safety net status is associated with increased use of mechanical valves for surgical aortic valve replacement despite also being associated with increased perioperative complications, costs, and significant complications upon readmission. Ability to access adequate follow-up care may be an important consideration for surgical aortic valve replacement at safety net hospitals.
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Verma A, Tran Z, Sakowitz S, Hadaya J, Lee C, Madrigal J, Revels S, Benharash P. Hospital variation in the development of respiratory failure after pulmonary lobectomy: A national analysis. Surgery 2022; 172:379-384. [DOI: 10.1016/j.surg.2022.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/23/2022] [Accepted: 03/15/2022] [Indexed: 11/27/2022]
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Williamson CG, Hadaya J, Benharash P. Response. Chest 2021; 160:e373-e374. [PMID: 34625190 DOI: 10.1016/j.chest.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/02/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles.
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Misclassification of Safety Net Hospitals With National Data. Chest 2021; 160:e372-e373. [PMID: 34625189 DOI: 10.1016/j.chest.2021.05.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 11/21/2022] Open
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Shi X, Shen Y, Yang J, Du W, Yang J. The relationship of the geriatric nutritional risk index to mortality and length of stay in elderly patients with acute respiratory failure: A retrospective cohort study. Heart Lung 2021; 50:898-905. [PMID: 34411871 DOI: 10.1016/j.hrtlng.2021.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/26/2021] [Accepted: 07/28/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Elderly people with acute respiratory failure (ARF) have prolonged length of hospital stay (LOS) and high mortality rates. Malnutrition is negatively correlated with these LOS and mortality. However, no tools have been used to detect the risk of malnutrition and assist in designing nutritional support for these patients. The geriatric nutritional risk index (GNRI) is reported as a novel tool for evaluating the risk of malnutrition. The aim of this study is to explore the relationship of the GNRI score with mortality and LOS in elderly patients with ARF. METHODS Data of elderly patients diagnosed with ARF were retrieved from the Medical Information Mart for Intensive Care III (MIMIC-III) database. A total of 1250 patients were divided into two groups based on their GNRI score: the malnutrition risk group (GNRI ≤ 98) and no risk group (GNRI > 98). The primary endpoints of this study were hospital mortality and hospital LOS. RESULTS The higher GNRI score was associated with lower hospital mortality and shorter hospital LOS. Odds ratio (OR) for hospital mortality of patients with nutritional risk (GNRI ≤ 98) was 1.264 (95% CI:1.067-1.497) in the adjusted model. Patients with GNRI ≤98 had longer hospital LOS (adjusted OR: 1.142, 95%CI: 1.044-1.250) compared with those with GNRI > 98. Subgroup analysis showed that higher GNRI was only significantly associated with lower hospital mortality in the patients that did not undergo mechanical ventilator (MV) treatment (adjusted OR: 0.985, 95% CI: 0.977-0.992, P < 0.01). Kaplan-Meier curve analysis showed that the 90-day survival was significantly lower in the group with nutrition risk (GNRI≤98) compared with the no risk group (GNRI > 98, p < 0.05). CONCLUSION These findings imply that GNRI is a useful prognostic tool in elderly patients with ARF.
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Affiliation(s)
- Xiawei Shi
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Yueqian Shen
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Jia Yang
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Wurong Du
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Junchao Yang
- Department of Respiratory Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University, No.54 Youdian Road, Shangcheng District, Hangzhou, Zhejiang 310006, China.
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