Portending Influence of Racial Disparities on Extended Length of Stay after Elective Anterior Cervical Discectomy and Interbody Fusion for Cervical Spondylotic Myelopathy

Impact of Racial/Ethnic Disparities on Patient-Reported Outcomes Following Cervical Spine Surgery: QOD Analysis

STUDY DESIGN

Retrospective analysis of data from the cervical module of a National Spine Registry, the Quality Outcomes Database.

OBJECTIVE

To examine the association of race and ethnicity with patient-reported outcome measures (PROMs) at one year after cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Evidence suggests that Black individuals are 39% to 44% more likely to have postoperative complications and a prolonged length of stay after cervical spine surgery compared with Whites. The long-term recovery assessed with PROMs after cervical spine surgery among Black, Hispanic, and other non-Hispanic groups ( i.e . Asian) remains unclear.

MATERIALS AND METHODS

PROMs were used to assess disability (neck disability index) and neck/arm pain preoperatively and one-year postoperative. Primary outcomes were disability and pain, and not being satisfied from preoperative to 12 months after surgery. Multivariable logistic and proportional odds regression analyses were used to determine the association of racial/ethnic groups [Hispanic, non-Hispanic White (NHW), non-Hispanic Black (NHB), and non-Hispanic Asian (NHA)] with outcomes after covariate adjustment and to compute the odds of each racial/ethnic group achieving a minimal clinically important difference one-year postoperatively.

RESULTS

On average, the sample of 14,429 participants had significant reductions in pain and disability, and 87% were satisfied at one-year follow-up. Hispanic and NHB patients had higher odds of not being satisfied (40% and 80%) and having worse pain outcomes (30%-70%) compared with NHW. NHB had 50% higher odds of worse disability scores compared with NHW. NHA reported similar disability and neck pain outcomes compared with NHW.

CONCLUSIONS

Hispanic and NHB patients had worse patient-reported outcomes one year after cervical spine surgery compared with NHW individuals, even after adjusting for potential confounders, yet there was no difference in disability and neck pain outcomes reported for NHA patients. This study highlights the need to address inherent racial/ethnic disparities in recovery trajectories following cervical spine surgery.

Geospatial Evaluation of Disparities in Access to Cervical Spine Fusion in Metropolitan Areas Across the United States

STUDY DESIGN

Retrospective study with epidemiologic analysis of public Medicare data.

OBJECTIVE

The purpose of this study is to use geospatial analysis to identify disparities in access to cervical spine fusions in metropolitan Medicare populations.

SUMMARY OF BACKGROUND DATA

Cervical spine fusion is among the most common elective procedures performed by spine surgeons and is the most common surgical intervention for degenerative cervical spine disease. Although some studies have examined demographic and socioeconomic trends in cervical spine fusion, few have attempted to identify where disparities exist and quantify them at a community level.

METHODS

Center for Medicare and Medicaid Services physician billing and Medicare demographic data sets from 2013 to 2020 were filtered to contain only cervical spine fusion procedures and then combined with US Census socioeconomic data. The Moran Index geospatial clustering algorithm was used to identify statistically significant hotspot and coldspots of cervical spine fusions per 100,000 Medicare members at a county level. Univariate and multivariate analysis was subsequently conducted to identify demographic and socioeconomic factors that are associated with access to care.

RESULTS

A total of 285,405 cervical spine fusions were analyzed. Hotspots of cervical spine fusion were located in the South, while coldspots were throughout the Northern Midwest, the Northeast, South Florida, and West Coast. The percent of Medicare patients that were Black was the largest negative predictor of cervical spine fusions per 100,000 Medicare members ( β =-0.13, 95% CI: -0.16, -0.10).

CONCLUSIONS

Barriers to access can have significant impacts on health outcomes, and these impacts can be disproportionately felt by marginalized groups. Accounting for socioeconomic disadvantage and geography, this analysis found the Black race to be a significant negative predictor of access to cervical spine fusions. Future studies are needed to further explore potential socioeconomic barriers that exist in access to specialized surgical care.

LEVEL OF EVIDENCE

Level III-retrospective.

Clinicosocial determinants of hospital stay following cervical decompression: A public healthcare perspective and machine learning model

OBJECTIVE

Post-operative length of hospital stay (LOS) is a valuable measure for monitoring quality of care provision, patient recovery, and guiding hospital resource management. But the impact of patient ethnicity, socio-economic deprivation as measured by the indices of multiple deprivation (IMD), and pre-existing health conditions on LOS post-anterior cervical decompression and fusion (ACDF) is under-researched in public healthcare settings.

METHODS

From 2013 to 2023, a retrospective study at a single center reviewed all ACDF procedures. We analyzed 14 non-clinical predictors-including demographics, comorbidities, and socio-economic status-to forecast a categorized LOS: short (≤2 days), medium (2-3 days), or long (>3 days). Three machine learning (ML) models were developed and assessed for their prediction reliability.

RESULTS

2033 ACDF patients were analyzed; 79.44 % had a LOS ≤ 2 days. Significant predictors of LOS included patient sex (HR:0.81[0.74-0.88], p < 0.005), IMD decile (HR:1.38[1.24-1.53], p < 0.005), smoking (HR:1.24[1.12-1.38], p < 0.005), DM (HR:0.70[0.59-0.84], p < 0.005), and COPD (HR:0.66, p = 0.01). Asian patients had the highest mean LOS (p = 0.003). Testing on 407 patients, the XGBoost model achieved 80.95 % accuracy, 71.52 % sensitivity, 85.76 % specificity, 71.52 % positive predictive value, and a micro F1 score of 0.715. This model is available at: https://acdflos.streamlit.app.

CONCLUSIONS

Utilizing non-clinical pre-operative parameters such as patient ethnicity, socio-economic deprivation index, and baseline comorbidities, our ML model effectively predicts postoperative LOS for patient undergoing ACDF surgeries. Yet, as the healthcare landscape evolves, such tools will require further refinement to integrate peri and post-operative variables, ensuring a holistic decision support tool.

Addressing the Impact of Race and Ethnicity on Musculoskeletal Spine Care in the United States

➤ Despite being a social construct, race has an impact on outcomes in musculoskeletal spine care.➤ Race is associated with other social determinants of health that may predispose patients to worse outcomes.➤ The musculoskeletal spine literature is limited in its understanding of the causes of race-related outcome trends.➤ Efforts to mitigate race-related disparities in spine care require individual, institutional, and national initiatives.

Racial/Ethnic Disparities Among Patients Undergoing Anterior Cervical Discectomy and Fusion or Posterior Cervical Decompression and Fusion for Cervical Spondylotic Myelopathy: A National Administrative Database Analysis

INTRODUCTION

The aim of this study was to investigate the impact of racial disparities on surgical outcomes for cervical spondylotic myelopathy (CSM).

METHODS

Adult patients undergoing anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) for CSM were identified from the 2016 to 019 National Inpatient Sample Database using the International Classification of Diseases codes. Patients were categorized based on approach (ACDF or PCDF) and race/ethnicity (White, Black, Hispanic). Patient demographics, comorbidities, operative characteristics, adverse events, and health care resource utilization were assessed. Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay (LOS), nonroutine discharge (NRD), and exorbitant costs.

RESULTS

A total of 46,500 patients were identified, of which 36,015 (77.5%) were White, 7465 (16.0%) were Black, and 3020 (6.5%) were Hispanic. Black and Hispanic patients had a greater comorbidity burden compared to White patients (P = 0.001) and a greater incidence of any postoperative complication (P = 0.001). Healthcare resource utilization were greater in the PCDF cohort than the ACDF cohort and greater in Black and Hispanic patients compared to White patients (P < 0.001). Black and Hispanic patient race were significantly associated with extended hospital LOS ([Black] odds ratio [OR]: 2.24, P < 0.001; [Hispanic] OR: 1.64, P < 0.001) and NRD ([Black] OR: 2.33, P < 0.001; [Hispanic] OR: 1.49, P = 0.016). Among patients who underwent PCDF, Black race was independently associated with extended hospital LOS ([Black] OR: 1.77, P < 0.001; [Hispanic] OR: 1.47, P = 0.167) and NRD ([Black] OR: 1.82, P < 0.001; [Hispanic] OR: 1.38, P = 0.052).

CONCLUSIONS

Our study suggests that patient race may influence patient outcomes and healthcare resource utilization following ACDF or PCDF for CSM.

Racial Disparities in Spine Surgery: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVES

To synthesize previous studies evaluating racial disparities in spine surgery.

METHODS

We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on racial disparities in spine surgery. Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses guidelines and protocol. The main outcome measures were the occurrence of racial disparities in postoperative outcomes, mortality, surgical management, readmissions, and length of stay.

RESULTS

A total of 1753 publications were assessed. Twenty-two articles met inclusion criteria. Seventeen studies compared Whites (Ws) and African Americans (AAs) groups; 14 studies reported adverse outcomes for AAs. When compared with Ws, AA patients had higher odds of postoperative complications including mortality, cerebrospinal fluid leak, nervous system complications, bleeding, infection, in-hospital complications, adverse discharge disposition, and delay in diagnosis. Further, AAs were found to have increased odds of readmission and longer length of stay. Finally, AAs were found to have higher odds of nonoperative treatment for spinal cord injury, were more likely to undergo posterior approach in the treatment of cervical spondylotic myelopathy, and were less likely to receive cervical disk arthroplasty compared with Ws for similar indications.

CONCLUSIONS

This systematic review of spine literature found that when compared with W patients, AA patients had worse health outcomes. Further investigation of root causes of these racial disparities in spine surgery is warranted.

Racial disparities in surgical treatment of type A acute aortic dissection

Objective

To determine whether there are racial disparities associated with mortality, cost, and length of hospital stay after surgical repair of type A acute aortic dissection (TAAAD).

Methods

Patient data from 2015 to 2018 were collected using the National Inpatient Sample. In-hospital mortality was the primary outcome. Multivariable logistical modeling was used to identify factors independently associated with mortality.

Results

Among 3952 admissions, 2520 (63%) were White, 848 (21%) were Black/African American, 310 (8%) were Hispanic, 146 (4%) were Asian and Pacific Islander (API), and 128 (3%) were classified as Other. Black/African American and Hispanic admissions presented with TAAAD at a median age of 54 years and 55 years, respectively, whereas White and API admissions presented at a median age of 64 years and 63 years, respectively (P < .0001). Additionally, there were higher percentages of Black/African American (54%; n = 450) and Hispanic (32%; n = 94) admissions living in ZIP codes with the lowest median household income quartile. Despite these differences on presentation, when adjusting for age and comorbidity, there was no independent association between race and in-hospital mortality and no significant interactions between race and income on in-hospital mortality.

Conclusions

Black and Hispanic admissions present with TAAAD a decade earlier than White and API admissions. Additionally, Black and Hispanic TAAAD admissions are more likely to come from lower-income households. After adjusting for relevant cofactors, there was no independent association between race and in-hospital mortality after surgical treatment of TAAAD.

Impact of Race/Ethnicity on Hospital Resource Utilization After Elective Anterior Cervical Decompression and Fusion for Degenerative Myelopathy

INTRODUCTION

With the advent of bundled care payments for spine surgery, there is increasing scrutiny on the costs and resource utilization associated with surgical care. The purpose of this study was to compare (1) the total cost of the hospital episode of care and (2) discharge destination between White, Black, and Hispanic patients receiving elective anterior cervical decompression and fusion for degenerative cervical myelopathy (DCM) in Medicare patients.

METHODS

The 2019 Medicare Provider Analysis and Review Limited Data Set and the 2019 Impact File were used for this project. Multivariate models were created for total cost and discharge destination, controlling for confounders found on univariate analysis. We then performed a subanalysis for differences in specific cost-center charges.

RESULTS

There were 11,506 White (85.4%), 1,707 Black (12.7%), and 261 Hispanic (1.9%) patients identified. There were 6,447 males (47.8%) and 7,027 females (52.2%). Most patients were between 65 to 74 years of age (n = 7,101, 52.7%). The mean cost of the hospital episode was $20,919 ± 11,848. Most patients were discharged home (n = 11,584, 86.0%). Race/ethnicity was independently associated with an increased cost of care (Black: $783, Hispanic: $1,566, P = 0.001) and an increased likelihood of nonhome discharge (Black: adjusted odds ratio: 1.990, P < 0.001, Hispanic: adjusted odds ratio: 1.822, P < 0.001) compared with White patients. Compared with White patients, Black patients were charged more for accommodations ($1808), less for supplies (-$1780), and less for operating room (-$1072), whereas Hispanic patients were charged more ($3556, $7923, and $5162, respectively, P < 0.05).

CONCLUSION

Black and Hispanic race/ethnicity were found to be independently associated with an increased cost of care and risk for nonhome discharge after elective anterior cervical decompression and fusion for DCM compared with White patients. The largest drivers of this disparity appear to be accommodation, medical/surgical supply, and operating room-related charges. Further analysis of these racial disparities should be performed to improve value and equity of spine care for DCM.

Racial Differences in Patients Undergoing Anterior Cervical Discectomy and Fusion: A Multi-Site Study

STUDY DESIGN

This was a retrospective chart review.

OBJECTIVE

The objective of this study was to examine disparities within patients undergoing anterior cervical discectomy and fusion (ACDF) at a multi-site tertiary referral center with specific focus on factors related to length of stay (LOS).

SUMMARY OF BACKGROUND DATA

There are previously described racial disparities in spinal surgery outcomes and quality metrics.

METHODS

A total of 278 consecutive patients undergoing ACDF by 8 different surgeons over a 5-year period were identified retrospectively. Demographic data, including age at time of surgery, sex, smoking status, and self-identified race [White or African American (AA)], as well as surgical data and postoperative course were recorded. Preoperative health status was recorded, and comorbidities were scored by the Charlson Comorbidity Index. Univariable and multivariable linear regression models were employed to quantify the degree to which a patient's LOS was related to their self-identified race, demographics, and perioperative clinical data.

RESULTS

Of the 278 patients who received an ACDF, 71.6% (199) self-identified as White and 28.4% (79) identified as AA. AA patients were more likely to have an ACDF due to myelopathy, while White patients were more likely to have an ACDF due to radiculopathy (P=0.001). AA patients had longer LOS by an average of half a day (P=0.001) and experienced a larger percentage of extended stays (P=0.002). AA patients experienced longer overall operation times on average (P=0.001) across all different levels of fusion. AA race was not an independent driver of LOS (β=0.186; P=0.246).

CONCLUSIONS

As hypothesized, and consistent with previous literature on racial surgical disparities, AA race was associated with increased LOS, increased operative times, and increased indication of myelopathy in this study. Additional research is necessary to evaluate the underlying social determinants of health and other factors that may contribute to this study's results.

LEVEL OF EVIDENCE

Level III.

Geographic variations in health care resource utilization following elective ACDF for cervical spondylotic myelopathy: A national trend analysis

BACKGROUND

As health care expenditures continue to increase, standardizing health care delivery across geographic regions has been identified as a method to reduce costs. However, few studies have demonstrated how the practice of elective spine surgery varies by geographic location. The aim of this study was to assess the geographic variations in management, complications, and total cost of elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM).

METHODS

The National Inpatient Sample database (2016-2017) was queried using the ICD-10-CM procedural and diagnostic coding systems to identify all adult (≥18 years) patients with a primary diagnosis of CSM undergoing an elective ACDF. Patients were divided into regional cohorts as defined by the U.S. Census Bureau: Northeast, Midwest, South, and West. Weighted patient demographics, Elixhauser comorbidities, perioperative complications, length of stay (LOS), discharge disposition, and total cost of admission were assessed.

RESULTS

A total of 17,385 adult patients were identified. While the age (p=0.116) and proportion of female patients (p=0.447) were similar among the cohorts, race (p<0.001) and healthcare coverage (p<0.001) varied significantly. The Northeast had the largest proportion of patients in the 76-100th household income quartile (Northeast: 32.1%; Midwest: 16.9%; South: 15.7%; West: 27.5%, p<0.001). Complication rates were similar between regional cohorts (Northeast: 10.1%; Midwest: 12.2%; South: 10.3%; West: 11.9%, p=0.503), as was LOS (Northeast: 2.2±2.4 days; Midwest: 2.1±2.4 days; South: 2.0±2.5 days; West: 2.1±2.4 days, p=0.678). The West incurred the greatest mean total cost of admission (Northeast: $19,167±10,267; Midwest: $18,903±9,114; South: $18,566±10,152; West: $24,322±15,126, p<0.001). The Northeast had the lowest proportion of patients with a routine discharge (Northeast: 72.0%; Midwest: 84.8%; South: 82.3%; West: 83.3%, p<0.001). The odds ratio for Western hospital region was 3.46 [95% CI: (2.41, 4.96), p<0.001] compared to the Northeast for increased cost.

CONCLUSION

Our study suggests that regional variations exist in elective ACDF for CSM, including patient demographics, hospital costs, and nonroutine discharges, while complication rates and LOS were similar between regions.

Disparities in the Surgical Treatment of Adult Spine Diseases: A Systematic Review

BACKGROUND

Our goal was to systematically review the literature on racial/ethnic, insurance, and socioeconomic disparities in adult spine surgery in the United States and analyze potential areas for improvement.

METHODS

We conducted a database search of literature published between January 1990 and July 2020 using PRISMA guidelines for all studies investigating a disparity in any aspect of adult spine surgery care analyzed based on race/ethnicity, insurance status/payer, or socioeconomic status (SES).

RESULTS

Of 2679 articles identified through database searching, 775 were identified for full-text independent review by 3 authors, from which a final list of 60 studies were analyzed. Forty-three studies analyzed disparities based on patient race/ethnicity, 32 based on insurance status, and 8 based on SES. Five studies assessed disparities in access to care, 15 examined surgical treatment, 35 investigated in-hospital outcomes, and 25 explored after-discharge outcomes. Minority patients were less likely to undergo surgery but more likely to receive surgery from a low-volume provider and experience postoperative complications. White and privately insured patients generally had shorter hospital length of stay, were more likely to undergo favorable/routine discharge, and had lower rates of in-hospital mortality. After discharge, white patients reported better outcomes than did black patients. Thirty-three studies (55%) reported no disparities within at least 1 examined metric.

CONCLUSIONS

This comprehensive systematic review underscores ongoing potential for health care disparities among adult patients in spinal surgery. We show a need for continued efforts to promote equity and cultural competency within neurologic surgery.

Racial Disparities in Outcomes After Spine Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

Racial disparities are a major issue in health care but the overall extent of the issue in spinal surgery outcomes is unclear. We conducted a systematic review/meta-analysis of disparities in outcomes among patients belonging to different racial groups who had undergone surgery for degenerative spine disease.

METHODS

We searched Ovid MEDLINE, Scopus, Cochrane Review Database, and ClinicalTrials.gov from inception to January 20, 2021 for relevant articles assessing outcomes after spine surgery stratified by race. We included studies that compared outcomes after spine surgery for degenerative disease among different racial groups.

RESULTS

We found 30 studies that met our inclusion criteria (28 articles and 2 published abstracts). We included data from 20 cohort studies in our meta-analysis (3,501,830 patients), which were assessed to have a high risk of observation/selection bias. Black patients had a 55% higher risk of dying after spine surgery compared with white patients (relative risk [RR], 1.55, 95% confidence interval [CI], 1.28-1.87; I² = 70%). Similarly, black patients had a longer length of stay (mean difference, 0.93 days; 95% CI, 0.75-1.10; I² = 73%), and higher risk of nonhome discharge (RR, 1.63; 95% CI, 1.47-1.81; I² = 89%), and 30-day readmission (RR, 1.45; 95% CI, 1.03-2.04; I² = 96%). No significant difference was noted in the pooled analyses for complication or reoperation rates.

CONCLUSIONS

Black patients have a significantly higher risk of unfavorable outcomes after spine surgery compared with white patients. Further work in understanding the reasons for these disparities will help develop strategies to narrow the gap among the racial groups.

Racial Disparities Affecting Postoperative Outcomes After Brain Tumor Resection

OBJECTIVE

To investigate racial disparities in 30-day postoperative outcomes of craniotomy for glioma resection.

METHODS

2006-2019 American College of Surgeons' National Surgical Quality Improvement Program files were queried for all patients who underwent a craniotomy for a supratentorial glioma resection. Racial disparities in preoperative variables were studied between the demographic cohorts of Asian, African Americans, Hispanics, and Caucasian. Fisher exact tests were used to examine association of preoperative variables with race. Multivariable logistic regression models, adjusted for all preoperative variables associated with race, were used to determine the odds ratios of postoperative outcomes for each demographic cohort in comparison with Caucasian patients.

RESULTS

A total of 12,544 patients were identified: 4% Asian, 5% African American, 7% Hispanic, and 85% Caucasian. African American patients had significantly higher adjusted odds than Caucasian patients of major adverse cardiovascular events (adjusted odds ratio [aOR]: 1.827, 95% confidence interval [CI]: 1.155-2.891, P = 0.01), pulmonary events (aOR: 1.683, 95% CI: 1.145-2.473, P = 0.008), and urinary tract infection (aOR: 2.016, 95% CI: 1.221-3.327, P = 0.006). Asian patients had significantly higher odds than Caucasian patients of requiring a transfusion (aOR: 2.094, 95% CI: 1.343-3.266, P = 0.001). All demographic cohorts had higher odds of having an extended length of stay than Caucasian patients.

CONCLUSIONS

African American patients who undergo a craniotomy for glioma resection have almost twice the odds of Caucasian patients of having a postoperative major cardiovascular complication, pulmonary complication, or urinary tract infection. All minority groups have higher odds of an extended length of stay as compared with Caucasian patients.

Racial/ethnic and socioeconomic variations in hospital length of stay: A state-based analysis

Disparities by race/ethnicity and socioeconomic status (SES) exist in rehospitalization rates and inpatient mortality rates. Few studies have examined how length of stay (LOS, a measure of hospital efficiency/quality) differs by race/ethnicity and SES.This study's objective was to determine whether differences in risk-adjusted LOS exist by race/ethnicity and SESUsing a retrospective cohort of 1,432,683 medical and surgical discharges, we compared risk-adjusted LOS, in days, by race/ ethnicity and SES (median household income by patient ZIP code in quartiles), using generalized linear models controlling for demographic and clinical factors, and differences between hospitals and between diagnoses.White patients were on average older than both Black and Hispanic patients, had more chronic conditions, and had a higher inpatient mortality risk. In adjusted analyses, Black patients had a significantly longer LOS than White patients (0.25-day difference when discharged to home and 0.23-day difference when discharged to non-home destinations, both P<.001); there was no difference between Hispanic and White patients. Wealthier patients had a shorter LOS than poorer patients (0.16-day difference when discharged to home and 0.06-day difference when discharged to nonhome destinations, both P<.001). These differences by race/ethnicity reversed for Medicaid patients.Disparities in LOS exist based on a patient's race/ethnicity and SES. Black and poorer patients, but not Hispanic patients, have longer LOS compared to White and wealthier patients. In aggregate, these differences may be related to trust and implicit bias and have implications for use of LOS as a quality metric. Future research should examine the drivers of these disparities.

Trends in Medical and Surgical Admission Length of Stay by Race/Ethnicity and Socioeconomic Status: A Time Series Analysis

BACKGROUND

Length of stay (LOS), a metric of hospital efficiency, differs by race/ethnicity and socioeconomic status (SES) and longer LOS is associated with adverse health outcomes. Historically, projects to improve LOS efficiency have yielded LOS reductions by 0.3 to 0.7 days per admission.

OBJECTIVE

To assess differences in average adjusted length of stay (aALOS) over time by race/ethnicity, and SES stratified by discharge destination (home or non-home).

METHOD

Data were obtained from 2009-2014 Healthcare Cost and Utilization Project State Inpatient Datasets for New York, New Jersey, and Florida. Multivariate generalized linear models were used to examine trends in aALOS differences by race/ethnicity, and by high vs low SES patients (defined first vs fourth quartile of median income by zip code) controlling for patient, disease and hospital characteristics.

RESULTS

For those discharged home, racial/ethnic and SES aALOS differences remained stable from 2009 to 2014. However, among those discharged to non-home destinations, Black vs White aALOS differences increased from 0.21 days in Q1 2009, (95% confidence interval (CI): 0.13 to 0.30) to 0.32 days in Q3 2013, (95% CI: 0.23 to 0.40), and for low vs high SES patients from 0.03 days in Q1 2009 (95% CI: -0.04 to 0.1) to 0.26 days, (95% CI: 0.19 to 0.34). Notably, for patients not discharged home, racial/ethnic and SES aALOS differences increased and persisted after Q3 2011, coinciding with the introduction of the Affordable Care Act (ACA).

CONCLUSION

Further research to understand the ACA's policy impact on hospital efficiencies, and relationship to racial/ethnic and SES differences in LOS is warranted.