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Marano AA, Miller AS, Castillo W, Reisner SL, Schechter LS, Coon D. Social and Systemic Barriers to Transition-Related Surgical Procedures for Transgender Americans. LGBT Health 2024. [PMID: 38848247 DOI: 10.1089/lgbt.2023.0341] [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: 06/09/2024] Open
Abstract
Purpose: Transgender and gender-diverse (TGD) individuals in the United States face disproportionate barriers to health care access. This study compared characteristics of individuals who have and have not undergone gender-affirming surgery with the goal of identifying social and systemic barriers to transition-related surgery. Methods: Data were extracted from the 2015 United States Transgender Survey, a cross-sectional nonprobability sample of nearly 28,000 TGD adults. The primary outcome was having undergone gender-affirming surgery. Multivariable logistic regression models were constructed to determine correlates of receipt of gender-affirming surgery. A subgroup analysis was performed to explore differences by insurance types regarding coverage of surgical procedures and presence of in-network providers. Results: In total, 6009 (21.7%) participants underwent transition-related procedures. Increased odds of undergoing surgery were associated with older age, living in congruent gender, higher education attainment, and greater income. Decreased odds were linked with male sex assignment at birth, first recognizing TGD status at older ages, living in states without trans-protective health laws, no close transgender-knowledgeable health care provider, nonbinary status, and identifying as sexual minority. Residing in states without trans-protective health laws correlated with increased surgery denials over the previous 12-month period. Compared to White TGD individuals, TGD individuals who were Black, Latinx, or Another Race were significantly more likely to encounter health equity-related barriers to surgery. Conclusions: Gender-affirming surgery access is differentially distributed across demographic and modifiable equity-related factors amenable to interventions. Efforts are needed to address the number and geographic distribution of transgender health-competent providers, improve TGD legal protections, and increase access to health insurance for minority TGD individuals, who are disproportionately under/uninsured.
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Affiliation(s)
- Andrew A Marano
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amitai S Miller
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard University John F. Kennedy School of Government, Cambridge, Massachusetts, USA
| | - Wendy Castillo
- Princeton School of Public and International Affairs, Princeton University, Princeton, New Jersey, USA
| | - Sari L Reisner
- Division of Endocrinology, Diabetes, and Hypertension. Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Loren S Schechter
- Division of Plastic Surgery, Department of Surgery, Rush University, Chicago, Illinois, USA
| | - Devin Coon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Wu JY, Tang M, Touponse G, Theologitis M, Williamson T, Zygourakis CC. Socioeconomic disparities in lumbar fusion rates were exacerbated during the COVID-19 pandemic. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 18:100321. [PMID: 38741936 PMCID: PMC11089397 DOI: 10.1016/j.xnsj.2024.100321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 05/16/2024]
Abstract
Background The COVID-19 pandemic disrupted healthcare access and utilization throughout the US, with variable impact on patients of different socioeconomic status (SES) and race. We characterize pre-pandemic and pandemic demographic and SES trends of lumbar fusion patients in the US. Methods Adults undergoing first-time lumbar fusion 1/1/2004-3/31/2021 were assessed in Clinformatics® Data Mart for patient age, geographical location, gender, race, education level, net worth, and Charlson Comorbidity Index (CCI). Multivariable regression models were used to evaluate the significance of trends over time, with a focus on pandemic trends 2020-2021 versus previous trends 2004-2019. Results The total 217,204 patients underwent lumbar fusions, 1/1/2004-3/31/2021. The numbers and per capita rates of lumbar fusions increased 2004-2019 and decreased in 2020 (first year of COVID-19 pandemic), with large variation in geographic distribution. There was overall a significant decrease in proportion of White patients undergoing lumbar fusion over time (OR=0.997, p<.001), though they were more likely to undergo surgery during the pandemic (OR=1.016, p<.001). From 2004-2021, patients were more likely to be educated beyond high school. Additionally, patients in the highest (>$500k) and lowest (<$25k) net worth categories had significantly more fusions over time (p<.001). During the pandemic (2020-2021), patients in higher net worth groups were more likely to undergo lumbar fusions ($150k-249k & $250k-499k: p<.001) whereas patients in the lowest net worth group had decreased rate of surgeries (p<.001). Lastly, patients' CCI increased significantly from 2004 to 2021 (coefficient=0.124, p<.001), and this trend held true during the pandemic (coefficient=0.179, p<.001). Conclusions To the best of our knowledge, our work represents the most comprehensive and recent characterization of SES variables in lumbar fusion rates. Unsurprisingly, lumbar fusions decreased overall with the onset of the COVID-19 pandemic. Importantly, disparities in fusion patients across patient race and wealth widened during the pandemic, reversing years of progress, a lesson we can learn for future public health emergencies.
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Affiliation(s)
- Janet Y. Wu
- School of Medicine, Stanford University Medical Center, 291 Campus Drive, Stanford, CA 94305, United States
| | - Megan Tang
- Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, United States
| | - Gavin Touponse
- School of Medicine, Stanford University Medical Center, 291 Campus Drive, Stanford, CA 94305, United States
| | - Marinos Theologitis
- School of Medicine, University of Crete, Voutes Campus, P.O. Box 2208, 71003 Heraklion, Crete, Greece
| | - Theresa Williamson
- Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Corinna C. Zygourakis
- Department of Neurosurgery, Stanford University Medical Center, 453 Quarry Road Palo Alto, CA 94304, United States
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Rafaqat W, Lagazzi E, Jehanzeb H, Abiad M, Luckhurst CM, Parks JJ, Albutt KH, Hwabejire JO, DeWane MP. Does practice make perfect? The impact of hospital and surgeon volume on complications after intra-abdominal procedures. Surgery 2024; 175:1312-1320. [PMID: 38418297 DOI: 10.1016/j.surg.2024.01.011] [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: 08/08/2023] [Revised: 11/26/2023] [Accepted: 01/12/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND There is increasing interest in the regionalization of surgical procedures. However, evidence on the volume-outcome relationship for emergency intra-abdominal surgery is not well-synthesized. This systematic review and meta-analysis summarize evidence regarding the impact of hospital and surgeon volume on complications. METHODS We identified cohort studies assessing the impact of hospital/surgeon volume on postoperative complications after emergency intra-abdominal procedures, with data collected after the year 2000 through a literature search without language restriction in the PubMed, Web of Science, and Cochrane databases. A weighted overall complication rate was calculated, and a random effect regression model was used for a summary odds ratio. A sensitivity analysis with the removal of studies contributing to heterogeneity was performed (PROSPERO: CRD42022358879). RESULTS The search yielded 2,153 articles, of which 9 cohort studies were included and determined to be good quality according to the Newcastle Ottawa Scale. These studies reported outcomes for the following procedures: cholecystectomy, colectomy, appendectomy, small bowel resection, peptic ulcer repair, adhesiolysis, laparotomy, and hernia repair. Eight studies (2,358,093 patients) with available data were included in the meta-analysis. Low hospital volume was not significantly associated with higher complications. In the sensitivity analysis, low hospital volume was significantly associated with higher complications when appropriate heterogeneity was achieved. Low surgeon volume was associated with higher complications, and these findings remained consistent in the sensitivity analysis. CONCLUSION We found that hospital and surgeon volume was significantly associated with higher complications in patients undergoing emergency intra-abdominal surgery when appropriate heterogeneity was achieved.
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Affiliation(s)
- Wardah Rafaqat
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emanuele Lagazzi
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hamzah Jehanzeb
- Department of Surgery, Medical College, Aga Khan University, Karachi, Pakistan
| | - May Abiad
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Casey M Luckhurst
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jonathan J Parks
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Katherine H Albutt
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John O Hwabejire
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael P DeWane
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Abla H, Collins RA, Dhanasekara CS, Shrestha K, Dissanaike S. Using the Social Vulnerability Index to Analyze Statewide Health Disparities in Cholecystectomy. J Surg Res 2024; 296:135-141. [PMID: 38277949 DOI: 10.1016/j.jss.2023.12.031] [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: 08/16/2023] [Revised: 11/27/2023] [Accepted: 12/25/2023] [Indexed: 01/28/2024]
Abstract
INTRODUCTION Addressing the effects of social determinants of health in surgery has become a national priority. We evaluated the utility of the Social Vulnerability Index (SVI) in determining the likelihood of receiving cholecystectomy for cholecystitis in Texas. METHODS A retrospective study of adults with cholecystitis in the Texas Hospital Inpatient Discharge Public Use Data File and Texas Outpatient Surgical and Radiological Procedure Data Public Use Data File from 2016 to 2019. Patients were stratified into SVI quartiles, with the lowest quartile as low vulnerability, the middle two as average vulnerability, and the highest as high vulnerability. The relative risk (RR) of undergoing surgery was calculated using average vulnerability as the reference category and subgroup sensitivity analyses. RESULTS A total of 67,548 cases were assessed, of which 48,603 (72.0%) had surgery. Compared with the average SVI groups, the low vulnerability groups were 21% more likely to undergo cholecystectomy (RR = 1.21, 95% confidence interval [CI] 1.18-1.24), whereas the high vulnerability groups were 9% less likely to undergo cholecystectomy (RR = 0.91, 95% CI 0.88-0.93). The adjusted model showed similar results (RR = 1.05, 95% CI 1.04-1.06 and RR = 0.97, 95% CI 0.96-0.99, for low and high vulnerability groups, respectively). These results remained significant after stratifying for age, sex, ethnicity, and insurance status. However, the differences between low, average, and high vulnerability groups diminished in rural settings, with lower surgery rates in all groups. CONCLUSIONS Patients with higher SVI were less likely to receive an elective cholecystectomy. SVI is an effective method of identifying social determinants impacting access to and receipt of surgical care.
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Affiliation(s)
- Habib Abla
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas
| | - Reagan A Collins
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas
| | | | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas.
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Kim DK, Ascherman JA. Impact of Sociodemographic and Hospital Factors on Inpatient Bilateral Reduction Mammaplasty: A National Inpatient Sample Analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5682. [PMID: 38525492 PMCID: PMC10959567 DOI: 10.1097/gox.0000000000005682] [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: 10/09/2023] [Accepted: 01/22/2024] [Indexed: 03/26/2024]
Abstract
Background Although reduction mammaplasty remains a common procedure in plastic surgery, its interaction with sociodemographic and economic disparities has remained relatively uncharacterized on a nationwide scale. Methods Patients who underwent reduction mammaplasty were identified within the 2016-2018 National Inpatient Sample databases. In addition to clinical comorbidities, sociodemographic characteristics, hospital-level variables, and postoperative outcomes of each patient were collected for analysis. Statistical analyses, including univariate comparison and multivariate logistic regression, were applied to the cohort to determine significant predictors of adverse outcomes, described as extended length of stay, higher financial cost, and postoperative complications. Results The final patient cohort included 414 patients who underwent inpatient reduction mammaplasty. The average age was 45.2 ± 14.5 years. The average length of stay was 1.6 ± 1.5 days, and the average hospital charge was $53,873.81 ± $36,014.50. Sixty (14.5%) patients experienced at least one postoperative complication. Black race and treatment within a nonmetropolitan or rural county predicted postoperative complications (P < 0.01). Black race, lower relative income, and concurrent abdominal contouring procedures also predicted occurrence of extended length of stay (P < 0.01). Hospital factors, including larger bed capacity and for-profit ownership, predicted high hospital charges (P < 0.05). Severity of comorbidities, measured by a clinical index, also predicted all three outcomes (P < 0.001). Conclusion In addition to well-described clinical variables, multiple sociodemographic and economic disparities affect outcomes in inpatient reduction mammaplasty.
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Affiliation(s)
- Dylan K. Kim
- From the Division of Plastic Surgery, Columbia University Irving Medical Center, New York, N.Y
| | - Jeffrey A. Ascherman
- From the Division of Plastic Surgery, Columbia University Irving Medical Center, New York, N.Y
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Rafaqat W, Lagazzi E, Jehanzeb H, Abiad M, Hwabejire JO, Parks JJ, Kaafarani HM, DeWane MP. Which Volume Matters More? Systematic Review and Meta-Analysis of Hospital vs Surgeon Volume in Intra-Abdominal Emergency Surgery. J Am Coll Surg 2024; 238:332-346. [PMID: 37991251 DOI: 10.1097/xcs.0000000000000913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Affiliation(s)
- Wardah Rafaqat
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Emanuele Lagazzi
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Hamzah Jehanzeb
- Medical College, Aga Khan University, Karachi, Pakistan (Jehanzeb)
| | - May Abiad
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - John O Hwabejire
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Jonathan J Parks
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Haytham M Kaafarani
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Michael P DeWane
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
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Diaz A, Azap L, Moazzam Z, Knight-Davis J, Pawlik TM. Association of social determinants of health International Classification of Disease, Tenth Edition clinical modification codes with outcomes for emergency general surgery and trauma admissions. Surgery 2024; 175:899-906. [PMID: 37863693 DOI: 10.1016/j.surg.2023.08.046] [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: 05/10/2023] [Revised: 06/22/2023] [Accepted: 08/08/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Patients with Acute Care Surgery needs (ie, emergency general surgery diagnosis or trauma admission) are at particularly high risk for nonmedical patient-related factors that can be important drivers of healthcare outcomes. These social determinants of health are typically ascertained at the geographic area level (ie, county or neighborhood) rather than at the individual patient level. Recently, the International Classification of Diseases Tenth Revision, Tenth Edition created codes to capture health hazards related to patient socioeconomic and psychosocial circumstances. We sought to characterize the impact of these social determinants of health-related codes on perioperative outcomes among patients with acute care surgery needs. METHODS Patients diagnosed between 2017 and 2020 with acute care surgery needs (ie, emergency general surgery diagnosis or a trauma admission) were identified in the California Department of Healthcare Access and information Patient Discharge database. Data on concomitant social determinants of health-related codes (International Classification of Diseases Tenth Revision, Tenth Edition Z55-Z65), which designated health hazards related to socioeconomic and psychosocial (socioeconomic and psychosocial, respectively) circumstances, were obtained. After controlling for patient factors, including age, sex, race, payer type, and admitting hospital, the association of socioeconomic and psychosocial codes with perioperative outcomes and hospital disposition was analyzed. RESULTS Among 483,280 with an acute care surgery admission (emergency general surgery: n = 289,530, 59.9%; trauma: n = 193,705, 40.1%) mean age was 56.5 years (standard deviation: 21.5) and 271,911 (56.3%) individuals were male. Overall, 16,263 (3.4%) patients had a concomitant socioeconomic and psychosocial diagnosis code. The percentage of patients with a concurrent social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis increased throughout the study period from 2.6% in 2017 to 4.4% in 2020. Patients that were male (odds ratio 1.89; 95% confidence interval 1.82, 1.96), insured by Medicaid (odds ratio 5.43; 95% confidence interval 5.15, 5.72) or self-pay (odds ratio 3.04; 95% confidence interval 2.75, 3.36) all had higher odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. Black race did not have a significant association with an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis (odds ratio 0.99; 95% confidence interval 0.94, 1.04); however, Hispanic (odds ratio 0.44; 95% confidence interval 0.43, 0.46) and Asian (odds ratio 0.40; 95% confidence interval 0.36, 0.44) race/ethnicity was associated with a lower odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. After controlling for competing risk factors on multivariable analyses, the risk-adjusted probability of hospital postoperative death was 3.1% (95% confidence interval 2.8, 3.4) among patients with a social determinants of health diagnosis versus 5.9% (95% confidence interval 5.9, 6.0) (odds ratio 0.48; 95% confidence interval 0.44, 0.54) among patients without a social determinants of health diagnosis. Risk-adjusted complications were 26.7% (95% confidence interval 26.1, 37.3) among patients with a social determinants of health diagnosis compared with 31.9% (95% confidence interval 31.7, 32.0) (odds ratio 0.74; 95% confidence interval 0.71, 0.77) among patients without a social determinants of health diagnosis. CONCLUSION International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code use was low, with only 3.4% of patients having documentation of a socioeconomic and psychosocial circumstance. The presence of an International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code was not associated with greater odds of complications or death; however, it was associated with longer length of stay and higher odds of being discharged to a skilled nursing facility.
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Affiliation(s)
- Adrian Diaz
- The Ohio State University, Department of Surgery, Columbus, OH.
| | - Lovette Azap
- The Ohio State University, Department of Surgery, Columbus, OH
| | - Zorays Moazzam
- The Ohio State University, Department of Surgery, Columbus, OH
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Ferraro T, Ahmed AK, Lee E, Lee SM, Debbaneh PM, Thakkar P, Joshi A, Tummala N. Race and Ethnicity Independently Predict Adverse Outcomes Following Head and Neck Autograft Surgery. Laryngoscope 2024. [PMID: 38407481 DOI: 10.1002/lary.31367] [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: 01/16/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE There is growing attention toward the implications of race and ethnicity on health disparities within otolaryngology. While race is an established predictor of adverse head and neck oncologic outcomes, there is paucity in the literature on studies employing national, multi-institutional data to assess the impact of race and ethnicity on head and neck autograft surgery. METHODS Using the National Surgical Quality Improvement Program (NSQIP) database, trends in 30 days outcomes were assessed. Patients with ICD-10 codes for malignant head and neck neoplasms were isolated. Autograft surgeries were selected using Current Procedural Terminology (CPT) codes for free flap and pedicled flap reconstruction. Primary outcomes included surgical complications, reoperation, readmission, extended length of stay and operation time. Each binary categorical variable was compared to racial/ethnic identity via binary logistic regression. RESULTS The study cohort consisted of 2447 patients who underwent head and neck autograft surgery (80.71% free flap reconstruction and 19.39% pedicled flap reconstruction). Black patients had significantly higher odds of overall surgical complications (odds ratio [OR] 1.583, 95% confidence interval [CI] 1.091, 2.298, p = 0.016) with much higher odds of perioperative blood transfusions (OR 2.291, 95% CI 1.532, 3.426, p = <.001). Hispanic patients were more likely to undergo reoperation within 30 days after surgery and were more likely to be hospitalized for more than 30 days post-operatively (OR 1.566, 95% CI 1.015, 2.418, p = 0.043 and OR 12.224, 95% CI 2.698, 55.377, p = 0.001, respectively). CONCLUSIONS Race and ethnicity serve as independent predictors of complications in the post-operative period following head and neck autograft surgery. LEVEL OF EVIDENCE III Laryngoscope, 2024.
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Affiliation(s)
- Tatiana Ferraro
- Division of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, U.S.A
- Drexel University College of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Abdulla K Ahmed
- Division of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, U.S.A
| | - Esther Lee
- Division of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, U.S.A
| | - Sean M Lee
- Office of Clinical Research, The George Washington University School of Medicine & Health Sciences, Washington, DC, U.S.A
| | - Peter M Debbaneh
- Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente East Bay, Oakland, California, U.S.A
| | - Punam Thakkar
- Division of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, U.S.A
| | - Arjun Joshi
- Division of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, U.S.A
| | - Neelima Tummala
- Division of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, U.S.A
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Himmelstein KE, Afif IN, Beard JH, Tsai AC. Human Immunodeficiency Virus and Hepatitis C Virus-related Disparities in Undergoing Emergency General Surgical Procedures in the United States, 2016-2019. Ann Surg 2024; 279:240-245. [PMID: 37226805 PMCID: PMC10674045 DOI: 10.1097/sla.0000000000005918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To determine whether people living with human immunodeficiency virus (PLWHIV) and people living with hepatitis C virus (PLWHCV) experience inequities in receipt of emergency general surgery (EGS) care. BACKGROUND PLWHIV and PLWHCV face discrimination in many domains; it is unknown whether this extends to the receipt of EGS care. METHODS Using data from the 2016 to 2019 National Inpatient Sample, we examined 507,458 nonelective admissions of adults with indications for one of the 7 highest-burden EGS procedures (partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, or laparotomy). Using logistic regression, we evaluated the association between HIV/HCV status and the likelihood of undergoing one of these procedures, adjusting for demographic factors, comorbidities, and hospital characteristics. We also stratified analyses for the 7 procedures separately. RESULTS After adjustment for covariates, PLWHIV had lower odds of undergoing an indicated EGS procedure [adjusted odds ratio (aOR): 0.81; 95% CI: 0.73-0.89], as did PLWHCV (aOR: 0.66; 95% CI: 0.63-0.70). PLWHIV had reduced odds of undergoing cholecystectomy (aOR: 0.68; 95% CI: 0.58-0.80). PLWHCV had lower odds of undergoing cholecystectomy (aOR: 0.57; 95% CI: 0.53-0.62) or appendectomy (aOR: 0.76; 95% CI: 0.59-0.98). CONCLUSIONS PLWHIV and PLWHCV are less likely than otherwise similar patients to undergo EGS procedures. Further efforts are warranted to ensure equitable access to EGS care for PLWHIV and PLWHCV.
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Affiliation(s)
- Kathryn E.W. Himmelstein
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, US
- Harvard Medical School, Boston, MA, US
| | - Iman N. Afif
- Department of Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, US
| | - Jessica H. Beard
- Division of Trauma & Surgical Critical Care, Department of Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, US
| | - Alexander C. Tsai
- Harvard Medical School, Boston, MA, US
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, MA, US
- Harvard T.H. Chan School of Public Health, Boston, MA, US
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Silver DS, Beiriger J, Lu L, Peitzman AB, Neal MD, Brown JB. Evaluating potential disparities in geospatial access to American College of Surgeons/American Association for the Surgery of Trauma-verified emergency general surgery centers. J Trauma Acute Care Surg 2024; 96:225-231. [PMID: 37751150 PMCID: PMC10840782 DOI: 10.1097/ta.0000000000004147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND The American Association for the Surgery of Trauma and the American College of Surgeons have recently introduced emergency general surgery (EGS) center verification, which could enhance patient outcomes. Distance and resource availability may affect access to these centers, which has been linked to higher mortality. Although many patients can receive adequate care at community centers, those with critical conditions may require specialized treatment at EGS-verified centers. We aimed to evaluate geospatial access to potential EGS-verified centers and identify disparities across different scenarios of EGS verification program uptake in the United States. METHODS We used hospital capabilities and verified pilot centers to estimate potential patterns of which centers would become EGS verified under four scenarios (EGS centers, high-volume EGS centers, high-volume EGS plus level 1 trauma centers, and quaternary referral centers). We calculated the spatial accessibility index using an enhanced two-step floating catchment technique to determine geospatial access for each scenario. We also evaluated social determinants of health across geospatial access using the Area Deprivation Index (ADI). RESULTS A total of 1,932 hospitals were categorized as EGS centers, 307 as high-volume EGS centers, 401 as high-volume EGS plus level 1trauma centers, and 146 as quaternary centers. Spatial accessibility index decreased as the stringency of EGS verification increased in each scenario (226.6 [111.7-330.7], 51.8 [0-126.1], 71.52 [3.34-164.56], 6.2 [0-62.2]; p < 0.001). Within each scenario, spatial accessibility index also declined as the ADI quartile increased ( p < 0.001). The high-volume EGS plus level 1trauma center scenario had the most significant disparity in access between the first and fourth ADI quartiles (-54.68). CONCLUSION Access to EGS-verified centers may vary considerably based on the program's implementation. Disadvantaged communities may be disproportionately affected by limited access. Further work to study regional needs can allow a strategic implementation of the EGS verification program to optimize outcomes while minimizing disparities. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- David S Silver
- From the Division of General/Trauma Surgery, Department of Surgery (D.S.S., L.L., A.B.P., M.D.N., J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and Drexel School of Medicine (J.B.), Philadelphia, Pennsylvania
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11
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Ikram M, Shen C, Pameijer CR. Racial and Socioeconomic Differences and Surgical Outcomes in Pancreaticoduodenectomy Patients: A Systematic Review of High- Versus Low-Volume Hospitals in the United States. Am Surg 2024; 90:292-302. [PMID: 37941362 DOI: 10.1177/00031348231211040] [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: 11/10/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is associated with better outcomes in high-volume hospitals. However, it is unknown whether and to what extent the improved performance of high-volume hospitals may be associated with racial and socioeconomic factors, which have been shown to impact operative and postoperative outcomes in major surgeries. This review aims to identify the differences in racial and socioeconomic characteristics of patients who underwent PD surgery in high- and low-volume hospitals. METHODS PubMed, Cochrane, and Web of Science were systematically searched between May 1, 2023 and May 7, 2023 without any time restriction on publication date. Studies that were conducted in the United States and had a direct comparison between high- and low-volume hospitals were included. RESULTS A total of 30 observational studies were included. When racial proportions were compared by hospital volume, thirteen studies reported that compared to high-volume hospitals, a higher percentage of racial minorities underwent PD in low-volume hospitals. Disparities in traveling distance, education levels, and median income at baseline between high- and low-volume hospitals were reported by four, three, and two studies, respectively. CONCLUSION A racial difference at baseline between high- and low-volume hospitals was observed. Socioeconomic factors were less frequently included in existing literature. Future studies are needed to understand the socioeconomic differences between patients receiving PD surgery in high- and low-volume hospitals.
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Affiliation(s)
- Mohammad Ikram
- Department of Surgery, Division of Outcomes Research and Quality, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Chan Shen
- Department of Surgery, Division of Outcomes Research and Quality, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
- Department of Public Health Sciences, Division of Health Services and Behavioral Research, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Colette R Pameijer
- Department of Surgery, Division of Surgical Oncology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
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12
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Pant K, Haider SF, Turner AL, Merchant AM. The Association of Mental Illness With Outcomes of Emergency Surgery for Bowel Obstruction. J Surg Res 2023; 291:611-619. [PMID: 37542775 DOI: 10.1016/j.jss.2023.06.038] [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: 08/05/2022] [Revised: 06/13/2023] [Accepted: 06/27/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Bowel obstruction is one of the most common surgical emergencies. The management of SBO is variable and influenced by numerous confounding factors. Recent studies have identified mental health as a health disparity that affects surgical outcomes. We aim to assess whether mental illness is a health disparity and its association with postoperative complications and secondary outcomes for bowel obstruction in Emergency General Surgery (EGS). METHODS This was a retrospective study utilizing the National Inpatient Sample. Individuals aged 18-64 who underwent emergency adehesiolysis or bowel resection from 2015 to 2017 were identified. Postoperative complications, in-hospital mortality, length of stay, and total cost for surgical patients with and without mental illness were recorded. Univariate and multivariate analyses were used to evaluate the association between mental health and bowel obstruction. RESULTS 20,574 patients who underwent surgery for bowel obstruction were identified. 3756 of these patients had mental illness and 16,998 patients did not. Patients with mental illness did not have significantly worse outcomes compared to patients without mental illness. Among 3576 patients with mental illness, sex, race, patient location, insurance, location/teaching status of hospital, hospital control and procedure type were significant predictors of prolonged length of stay, higher cost, and increased postoperative complications. CONCLUSIONS Mental health does not appear to be a health disparity in outcomes for bowel obstruction procedures. However, the intersection of mental health with race and insurance status predicts worse outcomes. This essential area should be further explored to determine how marginalized populations are affected in emergency surgical care.
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Affiliation(s)
- Krittika Pant
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Syed F Haider
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Amber L Turner
- Department of Surgery, RWJBarnabas Health, Livingston, New Jersey
| | - Aziz M Merchant
- Department of Surgery, Hackensack Meridian JFK Medical Center, Edison, New Jersey.
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13
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Roberts SE, Rosen CB, Keele LJ, Kaufman EJ, Wirtalla CJ, Syvyk S, Reilly PM, Neuman MD, McHugh MD, Kelz RR. Conditional Effects of Race on Operative and Nonoperative Outcomes of Emergency General Surgery Conditions. Med Care 2023; 61:587-594. [PMID: 37476848 PMCID: PMC10527290 DOI: 10.1097/mlr.0000000000001883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Many emergency general surgery (EGS) conditions can be managed both operatively or nonoperatively; however, it is unknown whether the decision to operate affects Black and White patients differentially. METHODS We identified a nationwide cohort of Black and White Medicare beneficiaries, hospitalized for common EGS conditions from July 2015 to June 2018. Using near-far matching to adjust for measurable confounding and an instrumental variable analysis to control for selection bias associated with treatment assignment, we compare outcomes of operative and nonoperative management in a stratified population of Black and White patients. Outcomes included in-hospital mortality, 30-day mortality, nonroutine discharge, and 30-day readmissions. An interaction test based on a t test was used to determine the conditional effects of operative versus nonoperative management between Black and White patients. RESULTS A total of 556,087 patients met inclusion criteria, of which 59,519 (10.7%) were Black and 496,568 (89.3%) were White. Overall, 165,932 (29.8%) patients had an operation and 390,155 (70.2%) were managed nonoperatively. Significant outcome differences were seen between operative and nonoperative management for some conditions; however, no significant differences were seen for the conditional effect of race on outcomes. CONCLUSIONS The decision to manage an EGS patient operatively versus nonoperatively has varying effects on surgical outcomes. These effects vary by EGS condition. There were no significant conditional effects of race on the outcomes of operative versus nonoperative management among universally insured older adults hospitalized with EGS conditions.
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Affiliation(s)
- Sanford E. Roberts
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Claire B. Rosen
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Luke J. Keele
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Elinore J. Kaufman
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Christopher J. Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Solomiya Syvyk
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Patrick M. Reilly
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Mark D. Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA USA
| | - Matthew D. McHugh
- Center for Health Outcomes & Policy Research, University of Pennsylvania School of Nursing, University of Pennsylvania
| | - Rachel R. Kelz
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA USA
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14
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Kanney J, Distler K, Santini J, Rostedt L, Collopy K, Powers WF. Emergency General Surgery Transfers to Definitive Care: An Assessment of Patient and Systemic Factors in Appendicitis Referrals. Am Surg 2023; 89:3979-3981. [PMID: 37353395 DOI: 10.1177/00031348231173988] [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: 06/25/2023]
Abstract
Patients presenting to the emergency department (ED) with an Emergency General Surgery (EGS) problem often require transfer to a tertiary facility. Issues impacting EGS mirror the same issues trauma surgery faced prior to the implementation of current trauma guidelines. This study analyzed the cost, time, and transport resource utilization of EGS patients with acute appendicitis when transferred from network hospitals to a level II trauma center. This was a retrospective study. Patients were transferred by a critical or specialty care transport team 62% of the time, although no skills performed required a critical or specialty care provider. The median time from decision to transfer to incision was 254 minutes, with an average transport time of 27 minutes. This study suggests that there is an opportunity to improve access to the operating room and to decrease resource utilization of specialty care and critical care transport for patients.
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Affiliation(s)
- Jill Kanney
- Department of General Surgery, Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
| | - Katerina Distler
- AirLink/VitaLink Critical Care Transport, Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
| | - Jon Santini
- AirLink/VitaLink Critical Care Transport, Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
| | - Leslie Rostedt
- AirLink/VitaLink Critical Care Transport, Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
| | - Kevin Collopy
- AirLink/VitaLink Critical Care Transport, Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
| | - William F Powers
- Department of General Surgery, Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
- AirLink/VitaLink Critical Care Transport, Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
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15
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Bakillah E, Brown D, Syvyk S, Wirtalla C, Kelz RR. Barriers and facilitators to surgical access in underinsured and immigrant populations. Am J Surg 2023; 226:176-185. [PMID: 37156680 DOI: 10.1016/j.amjsurg.2023.04.003] [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] [Received: 01/02/2023] [Revised: 03/10/2023] [Accepted: 04/08/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Marginalized communities are at risk of receiving inequitable access to surgical care. We aimed to examine the barriers and facilitators to access to surgery in underinsured and immigrant populations. METHODS A systematic review of disparities in access to surgical care was performed between January 1, 2000-March 2, 2022. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A convergent integrated approach was used to code common themes between studies. RESULTS Of 1315 publications, a total of 66 studies were included for systematic review. Eight studies specifically discussed immigrant patient populations. Barriers and facilitators to surgical access were categorized by patient and health systems related factors. CONCLUSIONS Established facilitators to improve surgical access are centered on patient-level factors while interventions to address systems-related barriers are limited and may be an area for further investigation. Research focused on access to surgery in immigrant populations remains sparse.
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Affiliation(s)
- Emna Bakillah
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Danielle Brown
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Solomiya Syvyk
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Christopher Wirtalla
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Rachel R Kelz
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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16
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Frego N, D'Andrea V, Labban M, Trinh QD. An ecological framework for racial and ethnic disparities in surgery. Curr Probl Surg 2023; 60:101335. [PMID: 37316107 DOI: 10.1016/j.cpsurg.2023.101335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/14/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Nicola Frego
- Department of Urology, Istituto Clinico Humanitas IRCCS, Milan, Italy
| | - Vincent D'Andrea
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, MA
| | - Muhieddine Labban
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, MA
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, MA; Brigham and Women's Faulkner Hospital, Jamaica Plain, MA.
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17
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Blumenthal SR, Fryhofer GW, Serra-Lopez V, Pierrie SN, Mehta S. Bias in Care: Impact of Ethnicity on Time to Emergent Surgery Varies Between Subspecialties. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202306000-00007. [PMID: 37311114 DOI: 10.5435/jaaosglobal-d-23-00060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Disparity in access to emergency care among minority groups continues to exist despite growing awareness of the effect of implicit bias on public health. In this study, we evaluated ethnicity-based differences in time between admission and surgery for patients undergoing emergent procedures at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. METHODS We conducted a retrospective review of 249,296 National Surgical Quality Improvement Program cases from 2006 to 2018 involving general, orthopaedic, and vascular surgeries. Analysis of variance was used to compare "time to operating room" (OR) between ethnic groups. RESULTS Notable differences in time to OR were noted among general and vascular surgeries but not orthopaedic surgery. Post hoc comparison identified notable variation in general surgery between White and Black/African Americans. In vascular surgery, notable variations were identified between White and Black/African Americans and White and Native Hawaiian/Pacific Islanders. DISCUSSION These findings suggest that certain surgical subspecialties continue to exhibit disparities in care that may manifest as surgical delay, most notably between White and Black/African Americans. Interestingly, variation in time to OR for patients treated by orthopaedic surgery was not notable. Overall, these results highlight the need for additional research into the role of implicit bias in emergent surgical care in the United States.
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Affiliation(s)
- Sarah R Blumenthal
- From the University of Pennsylvania, Philadelphia, PA (Dr. Blumenthal, Dr. Fryhofer, Dr. Serra-Lopez, and Dr. Mehta) and Brooke Army Medical Center (Dr. Pierrie), Fort Sam Houston, TX
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18
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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: 1.0] [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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19
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Williamson CG, Richardson S, Ebrahimian S, Kronen E, Verma A, Benharash P. Identifying the origin of socioeconomic disparities in outcomes of major elective operations. Surg Open Sci 2023; 13:66-70. [PMID: 37181545 PMCID: PMC10173262 DOI: 10.1016/j.sopen.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/08/2023] [Indexed: 05/16/2023] Open
Abstract
Background While the impact of socioeconomic status (SES) on surgical outcomes has been examined in limited series, it remains a significant determinant of healthcare outcomes at the national level. Therefore, the current study aims to determine SES disparities at three time-points: hospital accessibility, in-hospital outcomes, and post-discharge consequences. Methods The Nationwide Readmissions Database 2010-2018 was used to isolate major elective operations. SES was assigned using previously coded median income quartiles as defined by patient zip-code, with low SES defined as the lowest quartile and high SES as the highest. Results Of an estimated 4,816,837 patients undergoing major elective operations, 1,037,689 (21.3 %) were categorized as low SES and 1,288,618 (26.5 %) as high. On univariate analysis and compared to those of low SES, high SES patients were more frequently treated at high-volume centers (70.9 vs 55.6 %, p < 0.001), had lower rates of in-hospital complications (24.0 vs 29.0 %, p < 0.001) and mortality (0.4 vs 0.9 %, p < 0.001) as well as less frequent urgent readmissions at 30- (5.7 vs 7.1 %, p < 0.001) and 90-day timepoints (9.4 vs 10.7 %, p < 0.001). On multivariable analysis, high SES patients had higher odds of treatment at high-volume centers (Odds: 1.87, 95 % CI: 1.71-2.06), and lower odds of perioperative complications (Odds: 0.98, 95 % CI: 0.96-0.99), mortality (Odds: 0.70, 95 % CI: 0.65-0.75), and urgent readmissions at 90-days (Odds: 0.95, 95 % CI: 0.92-0.98). Conclusion This study fills a much-needed gap in the current literature by establishing that all of the aforementioned timepoints include significant disadvantages for those of low socioeconomic status. Therefore, a multidisciplinary approach may be required for intervention to improve equity for surgical patients.
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Affiliation(s)
| | | | | | | | | | - Peyman Benharash
- Corresponding author at: UCLA Center for Health Sciences, 10833 Le Conte Avenue, Room 62-249, Los Angeles, CA 90095, United States of America.
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Devin CL, Shaffer VO. Social Determinants of Health and Impact in Perioperative Space. Clin Colon Rectal Surg 2023; 36:206-209. [PMID: 37113281 PMCID: PMC10125291 DOI: 10.1055/s-0043-1761155] [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: 01/30/2023]
Abstract
The Centers for Disease Control and Prevention (CDC) defines the social determinants of health (SDOH) as "the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a range of health, functioning, and quality-of-life outcomes and risks," which includes economic stability, access to quality health care, and physical environment. There is increasing evidence that SDOH have an impact in shaping a patient's access and recovery from surgery. This review evaluates the role surgeons play in reducing these disparities.
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Affiliation(s)
- Courtney L. Devin
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Virginia O. Shaffer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Willging A, Castro E, Galet C, Xu J. Exploring Outcomes Related to Residential Determinants in Acute Mesenteric Ischemia Patients. J Surg Res 2023; 289:69-74. [PMID: 37086598 DOI: 10.1016/j.jss.2023.03.036] [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: 12/05/2022] [Revised: 03/20/2023] [Accepted: 03/26/2023] [Indexed: 04/24/2023]
Abstract
INTRODUCTION To access the relationship between residential status and outcomes in surgical acute mesenteric ischemia (AMI) patients. METHODS Retrospective chart review of 153 AMI patients admitted to our institution between 2007 and 2021. Residential median income and Rural-Urban Commuting Area (RUCA) code were used as residential proxies. RESULTS Being of the female sex (odds ratio [OR] = 3.116 [1.276-7.609] P = 0.013) and having a vascular intervention performed (OR = 2.927 [1.087-7.883] P = 0.034) were both associated with a threefold increase in the risk of mortality. Increased age (OR = 1.037 [1.002-1.073] P = 0.039), elevated blood urea nitrogen (OR = 1.032 [1.012-1.051] P = 0.001), and living in higher residential income area (OR = 1.049 [1.009-1.091] P = 0.017) had a small, but statistically significant, increased risk of mortality. Patients in higher median income areas were less likely to undergo colonic resection (OR = 0.953 [0.911-0.997] P = 0.038) and tended to have a lower likelihood of receiving an ostomy (OR = 0.963 [0.927-1] P = 0.051). Being from urban or rural areas was not associated with mortality (OR = 1.565 [0.647-3.790] P = 0.321, although rural patients were more likely to undergo colon resection (OR = 2.183 [0.938-5.079] P = 0.070). Furthermore, rural patients were much more likely to be readmitted than urban dwellers (OR = 4.700 [1.022-21.618] P = 0.047). CONCLUSIONS AMI patients living in rural or small-town areas were more likely to be readmitted and tended to undergo colonic resection. Patients residing in higher income areas had a slightly higher risk of mortality but tended to be less likely to require ostomy or colonic resection. These findings suggest a potential need for postoperative care initiatives focused on AMI patients living in rural and lower income areas.
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Affiliation(s)
- Abbygale Willging
- Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Elvis Castro
- Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Colette Galet
- Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Jun Xu
- Department of Surgery, University of Iowa, Iowa City, Iowa.
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Cevallos P, Amakiri UO, Johnstone T, Kim TSE, Maheta B, Nazerali R, Sheckter C. Is Plastic Surgery Training Equitable? An Analysis of Health Equity across US Plastic Surgery Residency Programs. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4900. [PMID: 37035124 PMCID: PMC10079348 DOI: 10.1097/gox.0000000000004900] [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: 12/09/2022] [Accepted: 02/09/2023] [Indexed: 04/11/2023]
Abstract
Achieving health equity includes training surgeons in environments exemplifying access, treatment, and outcomes across the racial, ethnic, and socioeconomic spectrum. Increased attention on health equity has generated metrics comparing hospitals. To establish the quality of health equity in plastic and reconstructive surgery (PRS) residency training, we determined the mean equity score (MES) across training hospitals of US PRS residencies. Methods The 2021 Lown Institute Hospital Index database was merged with affiliated training hospitals of US integrated PRS residency programs. The Lown equity category is composed of three domains (community benefit, inclusivity, pay equity) generating a health equity grade. MES (standard deviation) was calculated and reported for residency programs (higher MES represented greater health equity). Linear regression modeled the effects of a program's number of training hospitals, safety net hospitals, and geographical region on MES. Results The MES was 2.64 (0.62). An estimated 5.9% of programs had an MES between 1-2. In total, 56.5% of programs had an MES between 2 and 3, and 37.7% had an MES of 3 or more. The southern region was associated with a higher MES compared with the reference group (Northeast) (P = 0.03). The number of safety net hospitals per program was associated with higher MES (P = 0.02). Conclusions Two out of three programs train residents in facilities failing to demonstrate high equity healthcare. Programs should promote health equity by diversifying care delivery through affiliated hospitals. This will aid in the creation of a PRS workforce trained to provide care for a socioeconomically, racially, and ethnically diverse population.
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Affiliation(s)
- Priscila Cevallos
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Palo Alto, Calif
- Geisel School of Medicine, Dartmouth University, Hanover, N.H
| | | | - Thomas Johnstone
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Palo Alto, Calif
| | - Trudy Sea-Eun Kim
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Palo Alto, Calif
| | - Bhagvat Maheta
- College of Medicine, California Northstate University, Elk Grove, Calif
| | - Rahim Nazerali
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Palo Alto, Calif
| | - Clifford Sheckter
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Palo Alto, Calif
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Lois A, Kohler JE, Monsell SE, Pullar KM, Victory J, Odom SR, Fischkoff K, Kaji AH, Evans HL, Sohn V, Kao LS, Dodwad SJ, Ehlers AP, Alam HB, Park PK, Krishnadasan A, Talan DA, Siparsky N, Price TP, Ayoung-Chee P, Chiang W, Salzberg M, Jones A, Kutcher ME, Liang MK, Thompson CM, Self WH, Bizzell B, Comstock BA, Lavallee DC, Flum DR, Fannon E, Kessler LG, Heagerty PJ, Lawrence SO, Pham TN, Davidson GH. A Video-Based Consent Tool: Development and Effect of Risk-Benefit Framing on Intention to Randomize. J Surg Res 2023; 283:357-367. [PMID: 36427446 DOI: 10.1016/j.jss.2022.10.089] [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: 03/15/2022] [Revised: 08/14/2022] [Accepted: 10/16/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Nearly 75% of clinical trials fail to enroll enough participants, and cohorts often fail to reflect the clinical and demographic diversity of at-risk populations. Effective recruitment strategies are critically important for successful clinical trials. Framing treatment risks are known to affect medical decision-making for both physicians and patients but has not been rigorously studied in surgical trials. We sought to examine the impact of a high-quality video-based consent tool and the effect of risk-benefit framing on patient willingness to participate in a surgical clinical trial. METHODS A standardized video consent was shown to all potential participants in the Comparison of Outcomes of antibiotic Drugs and Appendectomy (CODA) trial, a randomized controlled trial comparing antibiotics and surgery for acute appendicitis. We report (1) differences in recruitment between two versions of a video-based tool that differed in production quality and (2) the impact of risk-benefit framing on participant randomization rates. The reasons for declining randomization were also assessed. RESULTS Of 4697 eligible patients approached to participate in the CODA trial, 1535 (33% [95% confidence interval (CI): 31%-34%]) agreed to randomization; this did not change from video version 1 to version 2. There was no difference in participation between positively framed videos (32% [95% CI: 30%-34%]) versus negatively framed videos (33.0% [95% CI: 30.8-35.2]). The most common reason for declining participation was treatment preference (72% for surgery and 18% for antibiotics). CONCLUSIONS Neither the change from video 1 to video 2 nor the positive versus negative framing affected participant willingness to randomize. The stakeholder-informed video-based consenting tool used in CODA was an effective strategy for the recruitment of a heterogeneous patient population within the proposed study period.
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Loehrer AP, Chen L, Wang Q, Colla CH, Wong SL. Rural Disparities in Lung Cancer-directed Surgery: A Medicare Cohort Study. Ann Surg 2023; 277:e657-e663. [PMID: 36745766 PMCID: PMC9902761 DOI: 10.1097/sla.0000000000005091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The primary objective of this study was to determine the influence of rural residence on access to and outcomes of lung cancer-directed surgery for Medicare beneficiaries. SUMMARY OF BACKGROUND DATA Lung cancer is the leading cause of cancerrelated death in the United States and rural patients have 20% higher mortality. Drivers of rural disparities along the continuum of lung cancercare delivery are poorly understood. METHODS Medicare claims (2015-2018) were used to identify 126,352 older adults with an incident diagnosis of nonmetastatic lung cancer. Rural Urban Commuting Area codes were used to define metropolitan, micropolitan, small town, and rural site of residence. Multivariable logistic regression models evaluated influence of place of residence on 1) receipt of cancer-directed surgery, 2) time from diagnosis to surgery, and 3) postoperative outcomes. RESULTS Metropolitan beneficiaries had higher rate of cancer-directed surgery (22.1%) than micropolitan (18.7%), small town (17.5%), and isolated rural (17.8%) (P < 0.001). Compared to patients from metropolitan areas, there were longer times from diagnosis to surgery for patients living in micropolitan, small, and rural communities. Multivariable models found nonmetropolitan residence to be associated with lower odds of receiving cancer-directed surgery and MIS. Nonmetropolitan residence was associated with higher odds of having postoperative emergency department visits. CONCLUSIONS Residence in nonmetropolitan areas is associated with lower probability of cancer-directed surgery, increased time to surgery, decreased use of MIS, and increased postoperative ED visits. Attention to timely access to surgery and coordination of postoperative care for nonmetropolitan patients could improve care delivery.
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Affiliation(s)
- Andrew P. Loehrer
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Geisel School of Medicine at Dartmouth, Hanover, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Louisa Chen
- Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Qianfei Wang
- Geisel School of Medicine at Dartmouth, Hanover, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Carrie H. Colla
- Geisel School of Medicine at Dartmouth, Hanover, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Sandra L. Wong
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Geisel School of Medicine at Dartmouth, Hanover, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
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Iantorno SE, Bucher BT, Horns JJ, McCrum ML. Racial and ethnic disparities in interhospital transfer for complex emergency general surgical disease across the United States. J Trauma Acute Care Surg 2023; 94:371-378. [PMID: 36472477 PMCID: PMC10008022 DOI: 10.1097/ta.0000000000003856] [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: 12/12/2022]
Abstract
BACKGROUND Differential access to specialty surgical care can drive health care disparities, and interhospital transfer (IHT) is one mechanism through which access barriers can be realized for vulnerable populations. The association between race/ethnicity and IHT for patients presenting with complex emergency general surgery (EGS) disease is understudied. METHODS Using the 2019 Nationwide Emergency Department Sample, we identified patients 18 years and older with 1 of 13 complex EGS diseases based on International Classification of Diseases, Tenth Revision , diagnosis codes. The primary outcome was IHT. A series of weighted logistic regression models was created to determine the association of race/ethnicity with the primary outcome while controlling for patient and hospital characteristics. RESULTS Of 387,610 weighted patient encounters from 989 hospitals, 59,395 patients (15.3%) underwent IHT. Compared with non-Hispanic White patients, rates of IHT were significantly lower for non-Hispanic Black (15% vs. 17%; unadjusted odds ratio (uOR) [95% confidence interval (CI)], 0.58 [0.49-0.68]; p < 0.001), Hispanic/Latinx (HL) (9.0% vs. 17%; uOR [95% CI], 0.48 [0.43-0.54]; p < 0.001), Asian/Pacific Islander (Asian/PI) (11% vs. 17%; uOR [95% CI], 0.84 [0.78-0.91]; p < 0.001), and other race/ethnicity (12% vs. 17%; uOR [95% CI], 0.68 [0.57-0.81]; p < 0.001) patients. In multivariable models, the adjusted odds of IHT remained significantly lower for HL (adjusted odds ratio [95% CI], 0.76 [0.72-0.83]; p < 0.001) and Asian/PI patients (adjusted odds ratio [95% CI], 0.73 [0.62-0.86]; p < 0.001) but not for non-Hispanic Black and other race/ethnicity patients ( p > 0.05). CONCLUSION In a nationally representative sample of emergency departments across the United States, patients of minority race/ethnicity presenting with complex EGS disease were less likely to undergo IHT when compared with non-Hispanic White patients. Disparities persisted for HL and Asian/PI patients when controlling for comorbid conditions, hospital and residential geography, neighborhood socioeconomic status, and insurance; these patients may face unique barriers in accessing surgical care. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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Affiliation(s)
- Stephanie E. Iantorno
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
- Primary Children’s Hospital, Intermountain Healthcare, Salt Lake City, UT
| | - Brian T. Bucher
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
- Primary Children’s Hospital, Intermountain Healthcare, Salt Lake City, UT
| | - Joshua J Horns
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Marta L. McCrum
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
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26
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McCrum ML, Allen CM, Han J, Iantorno SE, Presson AP, Wan N. Greater spatial access to care is associated with lower mortality for emergency general surgery. J Trauma Acute Care Surg 2023; 94:264-272. [PMID: 36694335 PMCID: PMC10069479 DOI: 10.1097/ta.0000000000003837] [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: 01/26/2023]
Abstract
BACKGROUND Emergency general surgery (EGS) diseases are time-sensitive conditions that require urgent surgical evaluation, yet the effect of geographic access to care on outcomes remains unclear. We examined the association of spatial access with outcomes for common EGS conditions. METHODS A retrospective analysis of twelve 2014 State Inpatient Databases, identifying adults admitted with eight EGS conditions, was performed. We assessed spatial access using the spatial access ratio (SPAR)-an advanced spatial model that accounts for travel distance, hospital capacity, and population demand, normalized against the national mean. Multivariable regression models adjusting for patient and hospital factors were used to evaluate the association between SPAR with (a) in-hospital mortality and (b) major morbidity. RESULTS A total of 877,928 admissions, of which 104,332 (2.4%) were in the lowest-access category (SPAR, 0) and 578,947 (66%) were in the high-access category (SPAR, ≥1), were analyzed. Low-access patients were more likely to be White, male, and treated in nonteaching hospitals. Low-access patients also had higher incidence of complex EGS disease (low access, 31% vs. high access, 12%; p < 0.001) and in-hospital mortality (4.4% vs. 2.5%, p < 0.05). When adjusted for confounding factors, including presence of advanced hospital resources, increasing spatial access was protective against in-hospital mortality (adjusted odds ratio, 0.95; 95% confidence interval, 0.94-0.97; p < 0.001). Spatial access was not significantly associated with major morbidity. CONCLUSION This is the first study to demonstrate that geospatial access to surgical care is associated with incidence of complex EGS disease and that increasing spatial access to care is independently associated with lower in-hospital mortality. These results support the consideration of spatial access in the development of regional health systems for EGS care. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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Affiliation(s)
- Marta L McCrum
- From the Department of Surgery (M.L.M., S.E.I.), Surgical Population Analysis Research Core (M.L.M.), Statistical Design and Biostatistics Center (C.M.A., A.P.P.), and Department of Geography (J.H., N.W.), The University of Utah, Salt Lake City, Utah
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Reinke CE, Wang H, Thompson K, Paton BL, Sherrill W, Ross SW, Schiffern L, Matthews BD. Impact of COVID-19 on common non-elective general surgery diagnoses. Surg Endosc 2023; 37:692-702. [PMID: 35298704 PMCID: PMC8927521 DOI: 10.1007/s00464-022-09154-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/17/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND During the COVID-19 pandemic, public health and hospital policies were enacted to decrease virus transmission and increase hospital capacity. Our aim was to understand the association between COVID-19 positivity rates and patient presentation with EGS diagnoses during the COVID pandemic compared to historical controls. METHODS In this cohort study, we identified patients ≥ 18 years who presented to an urgent care, freestanding ED, or acute care hospital in a regional health system with selected EGS diagnoses during the pandemic (March 17, 2020 to February 17, 2021) and compared them to a pre-pandemic cohort (March 17, 2019 to February 17, 2020). Outcomes of interest were number of EGS-related visits per month, length of stay (LOS), 30-day mortality and 30-day readmission. RESULTS There were 7908 patients in the pre-pandemic and 6771 in the pandemic cohort. The most common diagnoses in both were diverticulitis (29.6%), small bowel obstruction (28.8%), and appendicitis (20.8%). The lowest relative volume of EGS patients was seen in the first two months of the pandemic period (29% and 40% decrease). A higher percentage of patients were managed at a freestanding ED (9.6% vs. 8.1%) and patients who were admitted were more likely to be managed at a smaller hospital during the pandemic. Rates of surgical intervention were not different. There was no difference in use of ICU, ventilator requirement, or LOS. Higher 30-day readmission and lower 30-day mortality were seen in the pandemic cohort. CONCLUSIONS In the setting of the COVID pandemic, there was a decrease in visits with EGS diagnoses. The increase in visits managed at freestanding ED may reflect resources dedicated to supporting outpatient non-operative management and lack of bed availability during COVID surges. There was no evidence of a rebound in EGS case volume or substantial increase in severity of disease after a surge declined.
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Affiliation(s)
- Caroline E. Reinke
- grid.427669.80000 0004 0387 0597Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC 28205 USA
| | - Huaping Wang
- grid.427669.80000 0004 0387 0597Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC 28205 USA
| | - Kyle Thompson
- grid.427669.80000 0004 0387 0597Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC 28205 USA
| | - B. Lauren Paton
- grid.427669.80000 0004 0387 0597Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC 28205 USA
| | - William Sherrill
- grid.427669.80000 0004 0387 0597Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC 28205 USA
| | - Samuel W. Ross
- grid.427669.80000 0004 0387 0597Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC 28205 USA
| | - Lynnette Schiffern
- grid.427669.80000 0004 0387 0597Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC 28205 USA
| | - Brent D. Matthews
- grid.427669.80000 0004 0387 0597Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC 28205 USA
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Ho VP, Ingraham AM, Santry HP. Invited Commentary: Moving the Dial on Outcomes for Unplanned Abdominal Surgery. J Am Coll Surg 2023; 236:218-219. [PMID: 36519919 PMCID: PMC10829075 DOI: 10.1097/xcs.0000000000000430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Vanessa P. Ho
- Acute Care Surgery, MetroHealth Medical Center, Cleveland OH
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland OH
| | - Angela M. Ingraham
- Department of Surgery, University of Wisconsin School of Medicine, Madison, WI
| | - Heena P. Santry
- Acute Care Surgery, Kettering Medical Center, Kettering OH
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH
- NBBJ, LLC, Columbus, OH
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Hwang F, Crandall M, Smith A, Parry N, Liepert AE. Small bowel obstruction in older patients: challenges in surgical management. Surg Endosc 2023; 37:638-644. [PMID: 35918548 DOI: 10.1007/s00464-022-09428-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 06/29/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Small bowel obstruction (SBO) is a common disease affecting all segments of the population, including the frail elderly. Recent retrospective data suggest that earlier operative intervention may decrease morbidity. However, management decisions are influenced by surgical outcomes. Our goal was to determine the current surgical management of SBO in older patients with particular attention to frailty and the timing of surgery. STUDY DESIGN A retrospective review of patients over the age of 65 with a diagnosis of bowel obstruction (ICD-10 K56*) using the 2016 National Inpatient Sample (NIS). Demographics included age, race, insurance status, medical comorbidities, and median household income by zip code. Elixhauser comorbidities were used to derive a previously published frailty score using the NIS dataset. Outcomes included time to operation, mortality, discharge disposition, and hospital length of stay. Associations between demographics, frailty, timing of surgery, and outcomes were determined. RESULTS 264,670 patients were included. Nine percent of the cohort was frail; overall mortality was 5.7%. Frail had 1.82 increased odds of mortality (95% CI 1.64-2.03). Hospital LOS was 1.6 times as long for frail patients; a quarter of the frail were discharged home. Frail patients waited longer for surgery (3.58 days vs 2.44 days; p < 0.001). Patients transferred from another facility had increased mortality (aOR 1.58; 95% CI 1.36-1.83). There was an increasing mortality associated with a delay in surgery. CONCLUSION Patients with frailty and SBO have higher mortality, more frequent discharge to dependent living, longer hospital length of stay, and longer wait to operative intervention. Mortality is also associated with male gender, black race, transfer status from another facility, self-pay status, and low household income. Every day in delay in surgical intervention for those who underwent operations led to higher mortality. If meeting operative indications, older patients with bowel obstruction have a higher chance of survival if they undergo surgery earlier.
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Affiliation(s)
- Franchesca Hwang
- Department of Surgery, New York University Grossman School of Medicine, New York, CA, USA
| | - Marie Crandall
- Department of Surgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Alan Smith
- Department of Surgery, University of California San Diego Health, 200 West Arbor Drive, #8896, San Diego, CA, 92103-8896, USA
| | - Neil Parry
- Departments of Surgery and Medicine, London Health Sciences Centre, Western University, London, ON, Canada
| | - Amy E Liepert
- Department of Surgery, University of California San Diego Health, 200 West Arbor Drive, #8896, San Diego, CA, 92103-8896, USA.
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Analysis of Outpatient Adherence in 45,237 Patients Referred by an Emergency Department to Surgical Clinics. World J Surg 2023; 47:455-460. [PMID: 36284006 PMCID: PMC9595074 DOI: 10.1007/s00268-022-06799-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2022] [Indexed: 01/29/2023]
Abstract
INTRODUCTION This study examines referral patterns to surgical clinics from the emergency department and the impact of sociodemographic factors on adherence. METHODS Patients from 2017 to 2021 were identified who had a referral placed to surgical specialties from the ED. The primary outcome was the proportion of patients who had a referral to surgery placed during an ED visit but who showed up to surgery clinic visit within 60 days of referral placement. Univariate and multivariate analysis was performed. RESULTS Referrals were made for 45,237 patients overall and 4130 for general surgery specifically. 44% showed up to general surgery clinic visit. In univariate and multivariate analysis, those who showed up to clinic were older, tended to be female, had a lower social economic status, had Medicaid or Medicare insurance and had more comorbidities compared to those who did not show up. Asians and Hispanics were more likely to show up to clinic compared to Whites. CONCLUSIONS Assigning navigators in the ED to follow-up with patients who are younger and healthier, with private insurances who have existing PCPs to ensure they follow up as advised is a potential targeted intervention to improve clinic adherence.
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Sherman WF, Patel AH, Ross BJ, Lee OC, Williams CS, Savoie FH. The Impact of a Non-Compete Clause on Patient Care and Orthopaedic Surgeons in the State of Louisiana: Afraid of a Little Competition? Orthop Rev (Pavia) 2022; 14:38404. [PMID: 36267544 PMCID: PMC9569414 DOI: 10.52965/001c.38404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Non-compete clauses (NCC) are commonly required for physicians practicing in an employed model. With growing pressures driving surgeons to practice in an employed model instead of physician-led practices, the purpose of this survey was to determine the impact of NCCs on orthopaedic surgeons and their patients in Louisiana. METHODS A voluntary, single-mode online survey containing 23 questions was created using the Qualtrics XM Platform (Qualtrics, Provo, UT) and distributed to 259 orthopaedic surgeons who are members of the Louisiana Orthopaedic Association. Survey questions assessed the prevalence and details of existing NCCs and perceptions of their impact on surgeons' practice, patients, and personal life. RESULTS 117 members responded (response rate: 45.2%), of which 91 (77.8%) finished the survey. Nearly half (44%) of respondents had an expired or active NCC in their contract. Most (84.3%) believed NCCs give employers unfair leverage during contract negotiations. NCCs have deterred or would deter 71.4% of respondents from accepting another job offer. Respondents believed NCCs negatively impact patients, including forcing patients to drive long distances to maintain continuity of care (64.4%) and forcing surgeons to abandon their patients if they seek new employment (76.7%). Many respondents reported NCCs also exert significant detrimental effects on their personal life, including mandatory relocation of their family (67.0%). Nearly all (97.8%) believed such clauses have become unreasonable over the last decade with the rise of large hospital conglomerates. Most surgeons (83.7%) believed that removal of NCCs from all orthopaedic surgeons' contracts would improve the overall healthcare of orthopaedic patients in Louisiana. CONCLUSION Perceptions of NCCs were overwhelmingly negative among orthopaedic surgeons in Louisiana. Such clauses give employers an unfair advantage during contract negotiations and exert a significant detrimental impact on surgeons and their patients. While NCCs may be reasonable in the business sector and other professions, it is unclear how such clauses benefit surgeons or improve patient care and may be detrimental to both. STUDY DESIGN Cross-sectional Survey.
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Affiliation(s)
| | - Akshar H Patel
- Orthopedic Surgery, Tulane University School of Medicine
| | - Bailey J Ross
- Orthopaedic Surgery, Tulane University School of Medicine
| | - Olivia C Lee
- Orthopedic Surgery, Louisiana State University Health Sciences Center New Orleans
| | | | - Felix H Savoie
- Orthopedic Surgery, Tulane University School of Medicine
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McCrum ML, Wan N, Han J, Lizotte SL, Horns JJ. Disparities in Spatial Access to Emergency Surgical Services in the US. JAMA HEALTH FORUM 2022; 3:e223633. [PMID: 36239953 PMCID: PMC9568808 DOI: 10.1001/jamahealthforum.2022.3633] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Importance Hospitals with emergency surgical services provide essential care for a wide range of time-sensitive diseases. Commonly used measures of spatial access, such as distance or travel time, have been shown to underestimate disparities compared with more comprehensive metrics. Objective To examine population-level differences in spatial access to hospitals with emergency surgical capability across the US using enhanced 2-step floating catchment (E2SFCA) methods. Design, Setting, and Participants A cross-sectional study using the 2015 American Community Survey data. National census block group (CBG) data on community characteristics were paired with geographic coordinates of hospitals with emergency departments and inpatient surgical services, and hospitals with advanced clinical resources were identified. Spatial access was measured using the spatial access ratio (SPAR), an E2SFCA method that captures distance to hospital, population demand, and hospital capacity. Small area analyses were conducted to assess both the population with low access to care and community characteristics associated with low spatial access. Data analysis occurred from February 2021 to July 2022. Main Outcomes and Measures Low spatial access was defined by SPAR greater than 1.0 SD below the national mean (SPAR <0.3). Results In the 217 663 CBGs (median [IQR] age for CBGs, 39.7 [33.7-46.3] years), there were 3853 hospitals with emergency surgical capabilities and 1066 (27.7%) with advanced clinical resources. Of 320 million residents, 30.8 million (9.6%) experienced low access to any hospital with emergency surgical services, and 82.6 million (25.8%) to advanced-resource centers. Insurance status was associated with low access to care across all settings (public insurance: adjusted rate ratio [aRR], 1.21; 95% CI, 1.12-1.25; uninsured aRR, 1.58; 95% CI, 1.52-1.64). In micropolitan and rural areas, high-share (>75th percentile) Hispanic and other (Asian; American Indian, Alaska Native, or Pacific Islander; and 2 or more racial and ethnic minority groups) communities were also associated with low access. Similar patterns were seen in access to advanced-resource hospitals, but with more pronounced racial and ethnic disparities. Conclusions and Relevance In this cross-sectional study of access to surgical care, nearly 1 in 10 US residents experienced low spatial access to any hospital with emergency surgical services, and 1 in 4 had low access to hospitals with advanced clinical resources. Communities with high rates of uninsured or publicly insured residents and racial and ethnic minority communities in micropolitan and rural areas experienced the greatest risk of limited access to emergency surgical care. These findings support the use of E2SFCA models in identifying areas with low spatial access to surgical care and in guiding health system development.
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Affiliation(s)
- Marta L. McCrum
- Division of General Surgery, University of Utah, Salt Lake City
| | - Neng Wan
- Department of Geography, University of Utah, Salt Lake City
| | - Jiuying Han
- Department of Geography, University of Utah, Salt Lake City
| | | | - Joshua J. Horns
- Surgical Population Analysis Research Core, Department of Surgery, University of Utah, Salt Lake City
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Hendrickson MJ, Arora S, Chew C, Sharma M, Yeung M, Fonarow GC, Yancy C, Byku M. Contemporary Trends and Comparison of Racial Differences in Hospitalizations of Adults With Congenital Heart Disease. Am J Cardiol 2022; 175:110-118. [PMID: 35589425 DOI: 10.1016/j.amjcard.2022.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 11/26/2022]
Abstract
As advancements in care improve longevity in patients with congenital heart disease (CHD), it is crucial to further characterize this rapidly growing adult population. It is also essential that equitable care is offered across demographic groups. Hospitalizations for adults with CHD in the National Inpatient Sample were identified to describe trends in overall and cause-specific rates of admission per 1,000 adults with CHD from 2000 to 2018. Primary admission causes were then analyzed and stratified by race. An aggregate rate of left-ventricular assist device placements and heart transplants was calculated for each group and trended over the years. A total of 1,562,001 weighted hospitalizations were identified. Overall, annual rates of hospital admissions increased from 39 per 1,000 adults with CHD in 2000 to 74 per 1,000 in 2018, as did rates of cardiovascular admissions (16 of 1,000 to 34 of 1,000, p <0.001 for both). Transient ischemic attack/stroke (2.5 of 1,000 to 10.7 of 1,000), coronary artery disease (4.1 of 1,000 to 5.6 of 1,000), arrhythmias (2.8 of 1,000 to 4.6 of 1,000), and heart failure (2.8 of 1,000 to 5.0 of 1,000) were the most common cardiovascular primary causes of admission (other than CHD itself), and each significantly increased over time (p <0.001 for each). Mean age at all-cause and primary heart failure hospitalization increased for all races but remained 7 to 9 years younger for Black and Hispanic adults than White adults. In conclusion, hospitalization rates of adults with CHD in the United States increased from 2000 to 2018, largely driven by an increase in adults ≥55 years. Although the age at hospitalization increased overall, Black and Hispanic patients were substantially younger at presentation for advanced heart failure. Anticoagulation guidelines in this population may need revisiting as transient ischemic attack/stroke hospitalizations were frequent.
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Affiliation(s)
- Michael J Hendrickson
- Department on Medicine, University of North Carolina School of Medicine, Chaple Hill, North Carolina
| | - Sameer Arora
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Christopher Chew
- Department on Medicine, University of North Carolina School of Medicine, Chaple Hill, North Carolina
| | - Mahesh Sharma
- Division of Cardiothoracic Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michael Yeung
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Gregg C Fonarow
- Division of Cardiology, University of California Los Angeles, Los Angeles, California
| | - Clyde Yancy
- Division of Cardiology, Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois
| | - Mirnela Byku
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
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Elkbuli A, Fanfan D, Newsome K, Sutherland M, Liu H, McKenney M, Ang D. A national evaluation of emergency department thoracotomy practices: Will a high-risk, low-yield procedure reveal potential management practice bias? Surgery 2022; 172:410-420. [PMID: 34972592 DOI: 10.1016/j.surg.2021.11.031] [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: 07/03/2021] [Revised: 11/17/2021] [Accepted: 11/29/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Emergency department thoracotomy is often performed on patients in extremis from traumatic exsanguination. Thus, inherent biases may play a role in whether or not the emergency department thoracotomy is performed. We aimed to investigate race, socioeconomic status, and gender disparities in the use of emergency department thoracotomy and to investigate outcomes of these patients to assess for possible surgeon practice bias. METHOD A nationwide retrospective cohort analysis of the American College of Surgeons Trauma Quality Programs Participant Use Profile 2016-2018. Adult patients who suffered blunt, penetrating, or other injuries secondary to falls/firearms/motor vehicle collision/other mechanisms of injury and presented to a trauma center pulseless, with or without signs of life after injury. Rates of thoracotomy, time to thoracotomy, transfer to operating room, emergency department disposition, intensive care unit length of stay, hospital length of stay, complications, mortality, and hospital disposition. Univariate analyses and adjusted multivariable regression were performed to account for confounders with significance defined as P < .05. RESULTS A total of 6,453 patients were analyzed. Emergency department thoracotomy and mortality were significantly higher in minorities and uninsured patients, even after risk adjustment. There were no differences in timing among race groups to emergency department thoracotomy. White/Caucasian patients experienced the highest rate of emergency department initial disposition to the intensive care unit (10.3%, P < .0001) and lowest mortality rate (89.2%, P < .0001). CONCLUSION Surgeon bias was not seen in the practice of emergency department thoracotomy for patients arriving pulseless. However, poorer outcomes were associated with minorities and lower socioeconomic status patients. Thoracotomy rates were higher in minorities and lower socioeconomic status patients due to more penetrating trauma.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL.
| | - Dino Fanfan
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Kevin Newsome
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Huazhi Liu
- Department of Surgery, Ocala Regional Medical Center, FL
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL; Department of Surgery, University of South Florida, Tampa, FL
| | - Darwin Ang
- Department of Surgery, Ocala Regional Medical Center, FL; Department of Surgery, University of Central Florida, Ocala, FL
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Hassanin S, Kshirsagar RS, Steele TO, Liang J. A Geospatial Analysis of the Rhinologist Workforce in the United States. Am J Rhinol Allergy 2022; 36:459-464. [PMID: 35098735 DOI: 10.1177/19458924221075887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Six percent of practicing otolaryngologists identified by the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) are rhinologists. This is the first study to investigate both the distribution of rhinologists in the United States and the sociodemographic characteristics that may predict their practice locations. OBJECTIVE We aim to describe the geospatial distribution of the rhinology workforce and analyze sociodemographic characteristics associated with practice distribution. METHODS We conducted a cross-sectional study of 662 rhinologists queried from the 2020 American Rhinologic Society (ARS) database. Rhinologist practice addresses were compared with ZIP code tabulation area (ZCTA) sociodemographic data from the 2010 US Census Bureau and from the 2014 to 2018 American Community Surveys. Geospatial mapping and multivariate statistics were employed to visualize rhinologist practice locations and analyze which community characteristics were associated with greater densities of rhinologists in ZCTAs. RESULTS The largest and smallest densities of rhinologists were in coastal areas and in the Central and Midwestern US, respectively. Population characteristics that significantly predicted a higher number of practicing rhinologists included: greater percentage of non-citizens and greater educational attainment (p < 0.001). Population characteristics that significantly predicted a lower number of practicing rhinologists included: greater percentage of self-identified white/Caucasians, median household income, and greater percentage of population aged 65 or older (p < 0.001). CONCLUSION Disparities in healthcare access in the US is evident and applies to rhinologic subspecialty care. Through visual geospatial analysis, we demonstrate the distribution of rhinologists and the population characteristics that may be predictive of whether patients have access to rhinological care.
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Affiliation(s)
- Samir Hassanin
- Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Rijul S Kshirsagar
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Jonathan Liang
- Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
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Edwards GC, Wong SL, Russell MC, Winslow ER, Shaffer VO, Pawlik TM. Society for Surgery of the Alimentary Tract Health Care Quality and Outcomes Committee Webinar: Addressing Disparities. J Gastrointest Surg 2022; 26:997-1005. [PMID: 35318595 DOI: 10.1007/s11605-022-05300-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/09/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Gretchen C Edwards
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandra L Wong
- Department of Surgery, Dartmouth-Hitchcock and Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Maria C Russell
- Department of Surgery, Winship Cancer Institute at Emory University, Atlanta, GA, USA
| | - Emily R Winslow
- Department of Surgery, Medstar Georgetown Medical Center, Washington, DC, USA
| | - Virginia O Shaffer
- Department of Surgery, Winship Cancer Institute at Emory University, Atlanta, GA, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Emanuelson RD, Brown SJ, Termuhlen PM. Interhospital Transfer (IHT) in Emergency General Surgery Patients (EGS): A Scoping Review. Surg Open Sci 2022; 9:69-79. [PMID: 35706931 PMCID: PMC9190042 DOI: 10.1016/j.sopen.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 05/14/2022] [Indexed: 11/26/2022] Open
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Boggs KM, Sullivan AF, Espinola JA, Gao J, Camargo CA. Evaluation of the American Hospital Association Annual Survey for health services research in emergency medicine. J Am Coll Emerg Physicians Open 2022; 3:e12704. [PMID: 35387323 PMCID: PMC8976194 DOI: 10.1002/emp2.12704] [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: 10/27/2021] [Revised: 02/08/2022] [Accepted: 02/23/2022] [Indexed: 11/07/2022] Open
Abstract
Objectives Emergency department (ED) data are often used to address questions about access to and quality of emergency care. Our objective was to compare one of the most commonly used data sources for national ED information, the American Hospital Association (AHA) Annual Survey, with a criterion database: the National Emergency Department Inventory (NEDI)–USA data set. Methods We compared the 2015 and 2016 AHA surveys to the following 3 criterion standards: (1) the 2015 and 2016 NEDI‐USA databases, which have information about all US EDs, including merged data from (2) Council of Teaching Hospitals (COTH) and (3) the Critical Access Hospital (CAH) program. We present descriptive results about the number of EDs in each data set; total and median visit volumes; locations in rural areas; and COTH, CAH, and freestanding ED (FSED) status. Results The AHA survey identified 3893 US EDs in 2015. These EDs had a total annual visit volume of 129,197,493 visits, with a median of 22,772 visits (interquartile range, 8311–47,938). Compared with the NEDI‐USA, the AHA included 1433 fewer EDs (−27%; 95% confidence interval [CI], −28% to −26%) and 23,615,163 (−15%) fewer visits. Specifically, AHA was missing 245 (−22%; 95% CI, −24% to −19%) of those located in rural areas, 268 (−20%; 95% CI, −22% to −18%) in a CAH, and 240 (−47%; 95% CI, −51% to −42%) FSEDs. We saw similar results using 2016 data. Conclusions Although several aggregated results were similar between the compared data sources, the AHA data set excluded many US EDs, including many rural EDs and FSEDs. Consequently, the AHA underreported total ED visits by 15%. We encourage data users to be cautious when interpreting results from any 1 ED data source, including the AHA.
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Affiliation(s)
- Krislyn M. Boggs
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Ashley F. Sullivan
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Janice A. Espinola
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Jingya Gao
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Carlos A. Camargo
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
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Hopper W, Zeller R, Burke R, Lindsey T. The association between operating margin and surgical diversity at Critical Access Hospitals. J Osteopath Med 2022; 122:339-345. [DOI: 10.1515/jom-2022-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/02/2022] [Indexed: 11/15/2022]
Abstract
Abstract
Context
Surgical volume is correlated with increased hospital profitability, yet many Critical Access Hospitals (CAHs) offer few or no inpatient surgical services.
Objectives
This study aims to investigate the impact of the presence of different inpatient surgical services on CAH profitability.
Methods
The study design was a cross-sectional analysis of financial data from the most recent fiscal year (FY) of 1299 CAHs. Multiple linear regression was utilized to assess how the operating margin was affected by the number of different inpatient surgical services offered per hospital. Covariates known to be associated with hospital profitability included occupancy rate, case mix index (CMI), system affiliation, ownership status (public, private, or nonprofit), and geographic region.
Results
The regression model for the CAH operating margin returned an R2 value of 0.18. Each additional inpatient surgical service corresponded to a 1.5% increase in operating margin (p=0.0413). Each 10% increase in occupancy rate and 0.1 increase in CMI corresponded to a 0.9% increase in operating margin (p=0.0032 and p=0.0176, respectively). The number of surgical services offered per CAH showed positive correlations with occupancy rate (r=0.23, p<0.0001) and CMI (r=0.59, p<0.0001).
Conclusions
A positive correlation exists between operating margin and the diversity of inpatient surgical specialties available at CAHs. Furthermore, providing surgery allows CAHs to accommodate higher occupancy rates and case mixes, both of which are significantly and positively correlated with CAH operating margin.
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Affiliation(s)
- Wade Hopper
- Department of Surgery , Edward Via College of Osteopathic Medicine , Spartanburg , SC , USA
| | - Robert Zeller
- Department of Surgery , Edward Via College of Osteopathic Medicine , Spartanburg , SC , USA
| | - Rachel Burke
- Department of Surgery , Edward Via College of Osteopathic Medicine , Spartanburg , SC , USA
| | - Tom Lindsey
- Department of Surgery , Edward Via College of Osteopathic Medicine , Spartanburg , SC , USA
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Adler RR, Smith RN, Fowler KJ, Gates J, Jefferson NM, Adler JT, Patzer RE. Community Based Participatory Research (CBPR): An Underutilized Approach to Address Surgical Disparities. Ann Surg 2022; 275:496-499. [PMID: 34913903 DOI: 10.1097/sla.0000000000005329] [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: 11/26/2022]
Abstract
Disparities are well-documented across the continuum of surgical care. Counteracting such disparities requires new multidisciplinary approaches that utilize the expertise of affected individuals, such as community-based participatory research (CBPR). CBPR is an approach to research that is anchored in equitable, sustainable community-academic partnerships, and has been shown to improve intervention implementation and outcomes. In this article, community stakeholders and researchers outline the principles and benefits of CBPR, examples of CBPR in trauma and transplant, and future directions for CBPR within surgery.
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Affiliation(s)
- Rachel R Adler
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Randi N Smith
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | | | | | | | - Joel T Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, TX
| | - Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
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Ross SW, Reinke CE, Ingraham AM, Holena DN, Havens JM, Hemmila MR, Sakran JV, Staudenmayer KL, Napolitano LM, Coimbra R. Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues. J Am Coll Surg 2022; 234:214-225. [PMID: 35213443 DOI: 10.1097/xcs.0000000000000044] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery.
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Affiliation(s)
- Samuel W Ross
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Caroline E Reinke
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Angela M Ingraham
- University of Wisconsin School of Medicine and Public Health, Madison, WI (Ingraham)
| | - Daniel N Holena
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Holena)
| | - Joaquim M Havens
- Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA (Havens)
| | - Mark R Hemmila
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Joseph V Sakran
- Johns Hopkins University School of Medicine, Baltimore, MD (Sakran)
| | | | - Lena M Napolitano
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Loma Linda, CA (Coimbra)
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Jin ML, Brown MM, Patwa D, Nirmalan A, Edwards PA. Telemedicine, telementoring, and telesurgery for surgical practices. Curr Probl Surg 2021; 58:100986. [PMID: 34895561 DOI: 10.1016/j.cpsurg.2021.100986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Man Li Jin
- Resident in Ophthalmology, Henry Ford Hospital, Detroit, MI.
| | - Meghan M Brown
- Medical Student, Oakland University William Beaumont School of Medicine, Rochester, MI
| | - Dhir Patwa
- Medical Student, Wayne State University School of Medicine, Detroit, MI
| | - Aravindh Nirmalan
- Medical Student, Wayne State University School of Medicine, Detroit, MI
| | - Paul A Edwards
- Chairman, Department of Ophthalmology, Henry Ford Hospital, Detroit, MI
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In Brief. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.100987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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One-Year Outcomes Following Emergency Laparotomy: A Systematic Review. World J Surg 2021; 46:512-523. [PMID: 34837122 DOI: 10.1007/s00268-021-06385-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Emergency laparotomies (EL) are associated with significant morbidity and mortality. To date, 30-day mortality has been predominately reported, and been the focus of various national emergency laparotomy audits. Only a few studies have reported on the long-term mortality associated with EL. The aim of this study was to review the one-year mortality following EL. METHOD A systematic review was conducted using PRISMA guidelines to identify studies published in the last 10 years reporting on long-term mortality associated with EL. The data abstracted included: patient demographics, pathology or type of operation performed for EL, post-operative mortality at 7-day, 30-day, 90-day, 1-year, beyond 1-year and inpatient, functional outcomes and risk factors associated with mortality. A quality assessment of included studies was performed. RESULTS Fifteen studies reporting long-term outcomes associated with EL were identified, including the results of 48,023 patients. The indications and/or pathologies for ELs varied. The 30-day mortality after EL ranged from 5.3% to 21.8%, and the one-year mortality ranged from 15.1 to 47%. The mortality in the six studies focusing on elderly patients ranged from 30 to 47%. CONCLUSION The long-term mortality rate associated with EL is substantial. Further study is required to understand the 1-year mortality described in the studies and translate these findings for meaningful application into the clinical care of these patients.
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Teng CY, Davis BS, Kahn JM, Rosengart MR, Brown JB. Factors associated with potentially avoidable interhospital transfers in emergency general surgery-A call for quality improvement efforts. Surgery 2021; 170:1298-1307. [PMID: 34147261 PMCID: PMC8550996 DOI: 10.1016/j.surg.2021.05.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/09/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Emergency general surgery conditions are common, require urgent surgical evaluation, and are associated with high mortality and costs. Although appropriate interhospital transfers are critical to successful emergency general surgery care, the performance of emergency general surgery transfer systems remains unclear. We aimed to describe emergency general surgery transfer patterns and identify factors associated with potentially avoidable transfers. METHODS We performed a retrospective cohort study of emergency general surgery episodes in 8 US states using the 2016 Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases and the American Hospital Association Annual Surveys. We identified Emergency Department-to-Inpatient and Inpatient-to-Inpatient interhospital emergency general surgery transfers. Potentially avoidable transfers were defined as discharge within 72 hours after transfer without undergoing any procedure or operation at the destination hospital. We examined transfer incidence and characteristics. We performed multilevel regression examining patient-level and hospital-level factors associated with potentially avoidable transfers. RESULTS Of 514,410 adult emergency general surgery episodes, 26,281 (5.1%) involved interhospital transfers (Emergency Department-to-Inpatient: 65.0%, Inpatient-to-Inpatient: 35.1%). Over 1 in 4 transfers were potentially avoidable (7,188, 27.4%), with the majority occurring from the emergency department. Factors associated with increased odds of potentially avoidable transfers included self-pay (versus government insurance, odds ratio: 1.26, 95% confidence interval: 1.09-1.45, P = .002), level 1 trauma centers (versus non-trauma centers, odds ratio: 1.24, 95% confidence interval: 1.05-1.47, P = .01), and critical access hospitals (versus non-critical access, odds ratio: 1.30, 95% confidence interval: 1.15-1.47, P < .001). Hospital-level factors (size, trauma center, ownership, critical access, location) accounted for 36.1% of potentially avoidable transfers variability. CONCLUSION Over 1 in 4 emergency general surgery transfers are potentially avoidable. Understanding factors associated with potentially avoidable transfers can guide research, quality improvement, and infrastructure development to optimize emergency general surgery care.
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Affiliation(s)
- Cindy Y Teng
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Billie S Davis
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh PA
| | - Matthew R Rosengart
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. https://twitter.com/joshua_b_brown
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Li HW, Scanlon ML, Kisilu N, Litzelman DK. The role of community health workers in the surgical cascade: a scoping review. HUMAN RESOURCES FOR HEALTH 2021; 19:122. [PMID: 34602064 PMCID: PMC8489043 DOI: 10.1186/s12960-021-00659-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 09/15/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Community health workers (CHWs) can increase access to various primary healthcare services; however, their potential for improving surgical care is under-explored. We sought to assess the role of CHWs in the surgical cascade, defined as disease screening, linkage to operative care, and post-operative care. Given the well-described literature on CHWs and screening, we focused on the latter two steps of the surgical cascade. METHODS We conducted a scoping review of the peer-reviewed literature. We searched for studies published in any language from January 1, 2000 to May 1, 2020 using electronic literature databases including Pubmed/MEDLINE, Web of Science, SCOPUS, and Google Scholar. We included articles on CHW involvement in linkage to operative care and/or post-operative surgical care. Narrative and descriptive methods were used to analyze the data. RESULTS The initial search identified 145 articles relevant to steps in the surgical cascade. Ten studies met our inclusion criteria and were included for review. In linkage to care, CHWs helped increase surgical enrollment, provide resources for vulnerable patients, and build trust in healthcare services. Post-operatively, CHWs acted as effective monitors for surgical-site infections and provided socially isolated patients with support and linkage to additional services. The complex and wide-ranging needs of surgical patients illustrated the need to view surgical care as a continuum rather than a singular operative event. CONCLUSION While the current literature is limited, CHWs were able to maneuver complex medical, cultural, and social barriers to surgical care by linking patients to counseling, education, and community resources, as well as post-operative infection prevention services. Future studies would benefit from more rigorous study designs and larger sample sizes to further elucidate the role CHWs can serve in the surgical cascade.
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Affiliation(s)
- Helen W. Li
- Department of Surgery, Washington University School of Medicine in St Louis, St. Louis, MO United States of America
| | - Michael L. Scanlon
- Indiana University Center for Global Health, 702 Rotary Circle, Suite RO 101, Indianapolis, IN 46202 United States of America
| | - Nicholas Kisilu
- Department of General Surgery and Anesthesiology, Moi University School of Medicine, Eldoret, Kenya
| | - Debra K. Litzelman
- William M. Tierney Center for Health Services Research, Regenstrief Institute, Inc. and Indiana University School of Medicine, 1101 West 10th Street, Indianapolis, IN 46202 United States of America
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Teng CY, Davis BS, Rosengart MR, Carley KM, Kahn JM. Assessment of Hospital Characteristics and Interhospital Transfer Patterns of Adults With Emergency General Surgery Conditions. JAMA Netw Open 2021; 4:e2123389. [PMID: 34468755 PMCID: PMC8411299 DOI: 10.1001/jamanetworkopen.2021.23389] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Although patients with emergency general surgery (EGS) conditions frequently undergo interhospital transfers, the transfer patterns and associated factors are not well understood. OBJECTIVE To examine whether patients with EGS conditions are consistently directed to hospitals with more resources and better outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study performed a network analysis of interhospital transfers among adults with EGS conditions from January 1 to December 31, 2016. The analysis used all-payer claims data from the 2016 Healthcare Cost and Utilization Project state inpatient and emergency department databases in 8 states. A total of 728 hospitals involving 85 415 transfers of 80 307 patients were included. Patients were eligible for inclusion if they were 18 years or older and had an acute care hospital encounter with a diagnosis of an EGS condition as defined by the American Association for the Surgery of Trauma. Data were analyzed from January 1, 2020, to June 17, 2021. EXPOSURES Hospital-level measures of size (total bed capacity), resources (intensive care unit [ICU] bed capacity, teaching status, trauma center designation, and presence of trauma and/or surgical critical care fellowships), EGS volume (annual EGS encounters), and EGS outcomes (risk-adjusted failure to rescue and in-hospital mortality). MAIN OUTCOMES AND MEASURES The main outcome was hospital-level centrality ratio, defined as the normalized number of incoming transfers divided by the number of outgoing transfers. A higher centrality ratio indicated more incoming transfers per outgoing transfer. Multivariable regression analysis was used to test the hypothesis that a higher hospital centrality ratio would be associated with more resources, higher volume, and better outcomes. RESULTS Among 80 307 total patients, the median age was 63 years (interquartile range [IQR], 50-75 years); 52.1% of patients were male and 78.8% were White. The median number of outgoing and incoming transfers per hospital were 106 (IQR, 61-157) and 36 (IQR, 8-137), respectively. A higher log-transformed centrality ratio was associated with more resources, such as higher ICU capacity (eg, >25 beds vs 0-10 beds: β = 1.67 [95% CI, 1.16-2.17]; P < .001), and higher EGS volume (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = 0.78 [95% CI, 0-1.57]; P = .01). However, a higher log-transformed centrality ratio was not associated with better outcomes, such as lower in-hospital mortality (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = 0.30 [95% CI, -0.09 to 0.68]; P = .83) and lower failure to rescue (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = -0.50 [95% CI, -1.13 to 0.12]; P = .27). CONCLUSIONS AND RELEVANCE In this study, EGS transfers were directed to high-volume hospitals with more resources but were not necessarily directed to hospitals with better clinical outcomes. Optimizing transfer destination in the interhospital transfer network has the potential to improve EGS outcomes.
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Affiliation(s)
- Cindy Y. Teng
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Billie S. Davis
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Matthew R. Rosengart
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kathleen M. Carley
- Department of Computer Science, Carnegie Mellon University, Pittsburgh, Pennsylvania
- Department of Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
- Department of Public Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Jeremy M. Kahn
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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48
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McCrum ML. Invited commentary on: "Factors associated with potentially avoidable interhospital transfers in emergency general surgery-A call for quality improvement efforts". Surgery 2021; 170:1308-1309. [PMID: 34462120 DOI: 10.1016/j.surg.2021.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/26/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Marta L McCrum
- Department of Surgery, University of Utah, Salt Lake City, UT.
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Ayuso SA, Elhage SA, Cunningham KW, Britton Christmas A, Sing RF, Thomas BW, May AK, Reinke CE, Ross SW. Emergency General Surgery Regionalization: Retrospective Cohort Study of Emergency General Surgery Patients at a Tertiary Care Center. Am Surg 2021:31348211038577. [PMID: 34397281 DOI: 10.1177/00031348211038577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) patients presenting at tertiary care hospitals may bypass local hospitals with adequate resources. However, many tertiary care hospitals frequently operate at capacity. We hypothesized that understanding patient geographic origin could identify opportunities for enhanced system triage and optimization and be an important first step for EGS regionalization and care coordination that could potentially lead to improved utilization of resources. METHODS We analyzed patient zip code and categorized EGS patients who were cared for at our tertiary care hospital as potentially divertible if the southern region hospital was geographically closer to their home, regional hospital admission (RHA) patients, or local admission (LA) patients if the tertiary care facility was closer. Baseline characteristics and outcomes were compared for RHA and LA patients. RESULTS Of 14 714 EGS patients presenting to the tertiary care hospital, 30.2% were categorized as RHA patients. Overall, 1526 (10.4%) patients required an operation including 527 (34.5%) patients who were potentially divertible. Appendectomy and cholecystectomy comprised 66% of the operations for potentially divertible patients. Length of stay was not significantly different (P = .06) for RHA patients, but they did have lower measured short-term and long-term mortality when compared to their LA counterparts (P < .05). CONCLUSIONS EGS diagnoses and patient geocode analysis can identify opportunities to optimize regional operating room and bed utilization. Understanding where EGS patients are cared for and factors that influenced care facility will be critical for next steps in developing EGS regionalization within our system.
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Affiliation(s)
- Sullivan A Ayuso
- Department of Surgery, 22442Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Sharbel A Elhage
- Department of Surgery, 22442Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Kyle W Cunningham
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - A Britton Christmas
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Ronald F Sing
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Bradley W Thomas
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Addison K May
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Caroline E Reinke
- Division of Gastrointestinal and Minimally Invasive Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Samuel W Ross
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
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50
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Sutton E, Montgomery Rice V. Impact of the Lack of Diversity Within Surgery Career Pathways and Mitigating Factors. Am Surg 2021; 87:1713-1717. [PMID: 34355988 DOI: 10.1177/00031348211034755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The lack of diversity in surgical career pathways impacts the cultural competence of the learning and working environment, the variety of leadership styles found within surgical leadership, and the ability of an organization to achieve equity in the workplace due to ongoing mistrust and untouched bias. Leading mitigating factors include developing pathways for greater numbers of diverse people at the high school and college level and implicit bias training. Though educators have had some success with these factors in the initial stages of diversifying early pathways, these factors are not yet correlated to entry into a surgical career. Future solutions to the lack of diversity in surgery will be predicated on surgeons collectively valuing justice, equity, diversity, and inclusion.
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Affiliation(s)
- Erica Sutton
- 1374Morehouse School of Medicine, Atlanta, GA, USA
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