1
|
Watters JA, Banaag A, Massengill JC, Koehlmoos TP, Staat BC. Postpartum Opioid Use among Military Health System Beneficiaries. Am J Perinatol 2024; 41:60-66. [PMID: 34784618 DOI: 10.1055/s-0041-1740006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aim of the study is to evaluate the prevalence and factors associated with opioid prescriptions to postpartum patients among TRICARE beneficiaries receiving care in the civilian health care system versus a military health care facility. STUDY DESIGN We evaluated postpartum opioid prescriptions filled at discharge among patients insured by TRICARE Prime/Prime Plus using the Military Health System Data Repository between fiscal years 2010 to 2015. We included women aged 15 to 49 years old and excluded abortive pregnancy outcomes and incomplete datasets. The primary outcome investigated mode of delivery and demographics for those filling an opioid prescription. Secondary outcomes compared prevalence of filled opioid prescription at discharge for postpartum patients within civilian care and military care. RESULTS Of a total of 508,258 postpartum beneficiaries, those in civilian health care were more likely to fill a discharge opioid prescription compared with those in military health care (OR 3.9, 95% CI 3.8-3.99). Cesarean deliveries occurred less frequently in military care (26%) compared with civilian care (30%), and forceps deliveries occurred more frequently in military care (1.38%) compared with civilian care (0.75%). Women identified as Asian race were least likely to fill an opioid prescription postpartum (OR 0.79, 95% CI 0.75-0.83). Women aged 15 to 19 years had a lower odds of filling an opioid prescription (OR 0.83, 95% CI 0.80-0.86). Women associated with a senior officer rank were less likely to fill an opioid prescription postpartum (OR 0.83, 95% CI 0.73-0.91), while those associated with warrant officer rank were more likely to fill an opioid prescription (OR 1.14, 95% CI 1.06-1.23). CONCLUSION Our data indicates that women who received care in civilian facilities were more likely to fill an opioid prescription at discharge when compared with military facilities. Factors such as race and age were associated with opioid prescription at discharge. This study highlights areas for improvement for potential further studies. KEY POINTS · Opioid prescription patterns for postpartum women may vary across the country.. · Our study indicates postpartum patients in civilian care are more likely to fill opioids postpartum.. · This study highlights a population which may have an improved opioid prescribing pattern..
Collapse
Affiliation(s)
- Julie A Watters
- Department of Obstetrics and Gynecology, Naval Hospital Camp Pendleton, 200 Mercy Circle, Oceanside, California
- Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Amanda Banaag
- Center for Health Services Research, Henry M. Jackson Foundation, Bethesda, Maryland
| | - Jason C Massengill
- Department of Obstetrics and Gynecology, Wright-Patterson United States Air Force Medical Center, Dayton, Ohio
| | - Tracey P Koehlmoos
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Barton C Staat
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| |
Collapse
|
2
|
Bryce-Alberti M, Campos LN, Dey T, del Valle DD, Hill SK, Zaigham M, Vela A, Juran S, Anderson GA, Uribe-Leitz T. Availability of laparoscopic surgery in Mexico's public health system: a nationwide retrospective analysis. Lancet Reg Health Am 2023; 24:100556. [PMID: 37521438 PMCID: PMC10372900 DOI: 10.1016/j.lana.2023.100556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/02/2023] [Accepted: 07/04/2023] [Indexed: 08/01/2023]
Abstract
Background Laparoscopic surgery remains limited in low-resource settings. We aimed to examine its use in Mexico and determine associated factors. Methods By querying open-source databases, we conducted a nationwide retrospective analysis of three common surgical procedures (i.e., cholecystectomies, appendectomies, and inguinal hernia repairs) performed in Mexican public hospitals in 2021. Procedures were classified as laparoscopic based on ICD-9 codes. We extracted patient (e.g., insurance status), clinical (e.g., anaesthesia technique), and geographic data (e.g., region) from procedures performed in hospitals and ambulatories. Multivariable analysis with random forest modelling was performed to identify associated factors and their importance in adopting laparoscopic approach. Findings We included 97,234 surgical procedures across 676 public hospitals. In total, 16,061 (16.5%) were performed using laparoscopic approaches, which were less common across all procedure categories. The proportion of laparoscopic procedures per 100,000 inhabitants was highest in the northwest (22.2%, 16/72) while the southeast had the lowest (8.3%, 13/155). Significant factors associated with a laparoscopic approach were female sex, number of municipality inhabitants, region, anaesthesia technique, and type of procedure. The number of municipality inhabitants had the highest contribution to the multivariable model. Interpretation Laparoscopic procedures were more commonly performed in highly populated, urban, and wealthy northern areas. Access to laparoscopic techniques was mostly influenced by the conditions of the settings where procedures are performed, rather than patients' non-modifiable characteristics. These findings call for tailored interventions to sustainably address equitable access to minimally invasive surgery in Mexico. Funding None.
Collapse
Affiliation(s)
- Mayte Bryce-Alberti
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Faculty of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Letícia Nunes Campos
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Faculty of Medical Sciences, Universidade de Pernambuco, Recife, PE, Brazil
| | - Tanujit Dey
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Diana D. del Valle
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Sarah K. Hill
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Mehreen Zaigham
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Obstetrics and Gynecology, Institution of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Alejandro Vela
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Anesthesia, Complete Surgery Houston Northwest, Houston, TX, USA
| | - Sabrina Juran
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Geoffrey A. Anderson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Tarsicio Uribe-Leitz
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Department of Plastic Surgery, Boston Children's Hospital, Boston, MA, USA
- Epidemiology, Department of Sport and Health Sciences, Technical University Munich, Munich, Germany
| |
Collapse
|
3
|
Kopelman ZA, Baker TM, Aden JK, Ramirez CI. Postoperative Venous Thromboembolism Following Hysterectomy in the Department of Defense. Mil Med 2023:usad064. [PMID: 36892149 DOI: 10.1093/milmed/usad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/04/2022] [Accepted: 02/23/2023] [Indexed: 03/10/2023] Open
Abstract
INTRODUCTION Hysterectomy is the most common major gynecologic procedure performed in the USA. Surgical complications, such as venous thromboembolism (VTE), are known risks that can be mitigated by preoperative risk stratification and perioperative prophylaxis. Based on recent data, the current post-hysterectomy VTE rate is found to be 0.5%. Postoperative VTE significantly impacts health care costs and patients' quality of life. Additionally, for active duty personnel, it can negatively impact military readiness. We hypothesize that the incidence of post-hysterectomy VTE rates will be lower within the military beneficiary population because of the benefits of universal health care coverage. MATERIALS AND METHODS The Military Health System (MHS) Data Repository and Management Analysis and Reporting Tool was used to conduct a retrospective cohort study of postoperative VTE rates within 60 days of surgery among women who underwent a hysterectomy at a military treatment facility between October 1, 2013, and July 7, 2020. Patient demographics, Caprini risk assessment, preoperative VTE prophylaxis, and surgical details were obtained by chart review. Statistical analysis was performed using the chi-squared test and Student t-test. RESULTS Among the 23,391 women who underwent a hysterectomy at a military treatment facility from October 2013 to July 2020, 79 (0.34%) women were diagnosed with VTE within 60 days of their surgery. This post-hysterectomy VTE incidence rate (0.34%) is significantly lower than the current national rate (0.5%, P < .0015). There were no significant differences in postoperative VTE rates with regard to race/ethnicity, active duty status, branch of service, or military rank. Most women with post-hysterectomy VTE had a moderate-to-high (4.29 ± 1.5) preoperative Caprini risk score; however, only 25% received preoperative VTE chemoprophylaxis. CONCLUSION MHS beneficiaries (active duty personnel, dependents, and retirees) have full medical coverage with little to no personal financial burden for their health care. We hypothesized a lower VTE rate in the Department of Defense because of universal access to care and a presumed younger and healthier population. The postoperative VTE incidence was significantly lower in the military beneficiary population (0.34%) compared to the reported national incidence (0.5%). Additionally, despite all VTE cases having moderate-to-high preoperative Caprini risk scores, the majority (75%) received only sequential compression devices for preoperative VTE prophylaxis. Although post-hysterectomy VTE rates are low within the Department of Defense, additional prospective studies are needed to determine if stricter adherence to preoperative chemoprophylaxis can further reduce post-hysterectomy VTE rates within the MHS.
Collapse
Affiliation(s)
- Zachary A Kopelman
- Department of Gynecologic Surgery and Obstetrics, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Tieneka M Baker
- Department of Obstetrics and Gynecology, New Mexico Veterans Affairs Health Care System, Albuquerque, NM 87131, USA
| | - James K Aden
- Department of Graduate Medical Education, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Christina I Ramirez
- Department of Gynecologic Surgery and Obstetrics, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| |
Collapse
|
4
|
Crawford AM, Lightsey Iv HM, Xiong GX, Ye J, Call CM, Pomer A, Cooper Z, Simpson AK, Koehlmoos TP, Weissman JS, Schoenfeld AJ. Changes in Elective and Urgent Surgery Among TRICARE Beneficiaries During the COVID-19 Pandemic. Mil Med 2022; 188:usac391. [PMID: 36519498 DOI: 10.1093/milmed/usac391] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/14/2022] [Accepted: 11/22/2022] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND COVID-19 is known to have altered the capacity to perform surgical procedures in numerous health care settings. The impact of this change within the direct and private-sector settings of the Military Health System has not been effectively explored, particularly as it pertains to disparities in surgical access and shifting of services between sectors. We sought to characterize how the COVID-19 pandemic influenced access to care for surgical procedures within the direct and private-sector settings of the Military Health System. METHODS We retrospectively evaluated claims for patients receiving urgent and elective surgical procedures in March-September 2017, 2019, and 2020. The pre-COVID period consisted of 2017 and 2019 and was compared to 2020. We adjusted for sociodemographic characteristics, medical comorbidities, and region of care using multivariable Poisson regression. Subanalyses considered the impact of race and sponsor rank as a proxy for socioeconomic status. RESULTS During the period of the COVID-19 pandemic, there was no significant difference in the adjusted rate of urgent surgical procedures in direct (risk ratio, 1.00; 95% CI, 0.97-1.03) or private-sector (risk ratio, 0.99; 95% CI, 0.97-1.02) care. This was also true for elective surgeries in both settings. No significant disparities were identified in any of the racial subgroups or proxies for socioeconomic status we considered in direct or private-sector care. CONCLUSIONS We found a similar performance of elective and urgent surgeries in both the private sector and direct care during the first 6 months of the COVID-19 pandemic. Importantly, no racial disparities were identified in either care setting.
Collapse
Affiliation(s)
- Alexander M Crawford
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Harry M Lightsey Iv
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Grace X Xiong
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jamie Ye
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Alysa Pomer
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Tracey P Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
5
|
Roberts SE, Rosen CB, Wirtalla CJ, Finn CB, Kaufman EJ, Reilly PM, Syvyk S, McHugh MD, Kelz RR. Examining disparities among older multimorbid emergency general surgery patients: An observational study of Medicare beneficiaries. Am J Surg 2022; 225:1074-1080. [DOI: 10.1016/j.amjsurg.2022.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/26/2022] [Accepted: 11/19/2022] [Indexed: 11/22/2022]
|
6
|
Huttler A, Hong C, Shah DK. Racial and ethnic disparities in the surgical management of tubal ectopic pregnancy. F S Rep 2022; 3:311-316. [PMID: 36568938 PMCID: PMC9783145 DOI: 10.1016/j.xfre.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 12/27/2022] Open
Abstract
Objective To evaluate racial and ethnic disparities in the surgical management of ectopic pregnancy over time. Design Retrospective cohort study. Setting None. Patients Surgically-managed cases of patients with tubal ectopic pregnancy within the American College of Surgeons National Surgical Quality Improvement Program database between 2010 and 2019. Interventions None. Main outcome measures Surgical approach (laparoscopic compared with open) and procedure (salpingectomy compared with salpingostomy/other). Results Of 7791 patients undergoing surgical management of tubal ectopic pregnancy, 21.8% identified as Hispanic, 24.5% as Black, 9.4% as Asian/other, and 44.3% as White. Use of laparoscopy increased 1.3% per year from 81.4% in 2010 to 91.0% in 2019 (95% confidence interval [CI], 0.010-0.016). Odds of undergoing laparoscopic surgery were lower in Black (adjusted odds ratio [aOR] 0.52; 95% CI, 0.45-0.61) and Hispanic patients (aOR 0.52; 95% CI, 0.44-0.61) compared with White patients and remained similar over time. The use of salpingectomy increased by 1.1% per year from 80.6% in 2010 to 94.7% in 2019 (95% CI, 0.009-0.014). Odds of undergoing salpingectomy were higher among Black (aOR 1.78, 95% CI 1.43-2.23) and Hispanic patients (aOR 1.54; 95% CI, 1.24-1.93) and lower among Asian patients (aOR 0.73, 95% CI, 0.56-0.95) compared with White patients. These ratios remained similar for Black and Asian patients over time. Conclusions Despite the increased use of laparoscopy and salpingectomy in the surgical management of ectopic pregnancy over time, Black and Hispanic patients remain less likely to undergo minimally invasive surgery and more likely to undergo salpingectomy compared with White patients.
Collapse
Affiliation(s)
- Alexandra Huttler
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Philadelphia, Pennsylvania,Reprint requests: Alexandra Huttler, M.D., Department of Obstetrics and Gynecology, Pennsylvania Hospital, 2 Pine East 800 Spruce Street, Philadelphia, Pennsylvania 19107
| | - Christopher Hong
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Philadelphia, Pennsylvania,Division of Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Divya Kelath Shah
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
7
|
Koehlmoos TP, Korona-Bailey J, Janvrin ML, Madsen C. Racial Disparities in the Military Health System: A Framework Synthesis. Mil Med 2021; 187:e1114-e1121. [PMID: 34910808 DOI: 10.1093/milmed/usab506] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/25/2021] [Accepted: 12/11/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Racial disparities in health care are a well-documented phenomenon in the USA. Universal insurance has been suggested as a solution to mitigate these disparities. We examined race-based disparities in the Military Health System (MHS) by constructing and analyzing a framework of existing studies that measured disparities between direct care (care provided by military treatment facilities) and private sector care (care provided by civilian health care facilities). MATERIALS AND METHODS We conducted a framework synthesis on 77 manuscripts published in partnership with the Comparative Effectiveness and Provider-Induced Demand Collaboration Project that use MHS electronic health record data to present an overview of racial disparities assessed for multiple treatment interventions in a nationally representative, universally insured population. RESULTS We identified 32 studies assessing racial disparities in areas of surgery, trauma, opioid prescription and usage, women's health, and others. Racial disparities were mitigated in postoperative complications, trauma care, and cancer screenings but persisted in diabetes readmissions, opioid usage, and minimally invasive women's health procedures. CONCLUSION Universal coverage mitigates many, but not all, racial disparities in health care. An examination of a broader range of interventions, a closer look at variation in care provided by civilian facilities, and a look at the quality of care by race provide further opportunities for research.
Collapse
Affiliation(s)
- Tracey Pérez Koehlmoos
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA
| | - Jessica Korona-Bailey
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| | - Miranda Lynn Janvrin
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| | - Cathaleen Madsen
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| |
Collapse
|
8
|
Ptacek I, Aref-Adib M, Mallick R, Odejinmi F. Each Uterus Counts: A narrative review of health disparities in benign gynaecology and minimal access surgery. Eur J Obstet Gynecol Reprod Biol 2021; 265:130-136. [PMID: 34492607 DOI: 10.1016/j.ejogrb.2021.08.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/11/2021] [Accepted: 08/23/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Health disparities exposed by the Covid-19 pandemic have prompted healthcare professionals to investigate disparities within their own specialty. Racial and ethnic disparities in obstetrics are well documented but inequities in gynaecology are less well known. Our aim is to review the literature on two commonly performed procedures, hysterectomy and myomectomy, and one condition, ectopic pregnancy, to evaluate the prevalence of racial, ethnic and socioeconomic disparities in benign gynaecology and minimal access surgery. METHODS A narrative review of 33 articles identified from a Pubmed using the following search criteria; "race"; "ethnicity"; "socioeconomic status"; "disparity"; "inequity"; and "inequality". Case reports and papers assessing gynaecological malignancy were excluded. RESULTS Despite minimal access surgery having fewer complications and faster recovery than open surgery, US studies have shown that black and ethnic minority women are less likely than white women to have minimally invasive hysterectomies and myomectomies. Uninsured women and patients on Medicaid are also less likely to receive minimally invasive procedures. Contributing factors include fibroid size, geographic location and access to hospitals performing minimal access surgery, and the discontinuation of power morcellation. Ethnic minority women who receive minimally invasive myomectomy have been shown to have a higher risk of complications and prolonged recovery. Black and ethnic minority women also have a higher risk of morbidity and mortality from ectopic pregnancy and are more likely to receive surgical than medical management. CONCLUSION Extensive study from the US has demonstrated disparities in access to minimally invasive gynaecological surgery, whereas in the UK the data is infrequent, inconsistent and incomplete. Little is known about the influence of patient preference and counselling as well as institutional bias on health equity in gynaecology. Further research is necessary to identify interventions that mitigate these disparities in access and outcomes.
Collapse
Affiliation(s)
| | | | - Rebecca Mallick
- University Hospitals Sussex NHS Foundation Trust, United Kingdom
| | | |
Collapse
|
9
|
Ranjit A, Andriotti T, Madsen C, Koehlmoos T, Staat B, Witkop C, Little SE, Robinson J. Does Universal Coverage Mitigate Racial Disparities in Potentially Avoidable Maternal Complications? Am J Perinatol 2021; 38:848-856. [PMID: 31986540 DOI: 10.1055/s-0040-1701195] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Potentially avoidable maternity complications (PAMCs) have been validated as an indicator of access to quality prenatal care. African-American mothers have exhibited a higher incidence of PAMCs, which has been attributed to unequal health coverage. The objective of this study was to assess if racial disparities in the incidence of PAMCs exist in a universally insured population. STUDY DESIGN PAMCs in each racial group were compared relative to White mothers using multivariate logistic regression. Stratified subanalyses assessed for adjusted differences in the odds of PAMCs for each racial group within direct versus purchased care. RESULTS A total of 675,553 deliveries were included. Among them, 428,320 (63%) mothers were White, 112,170 (17%) African-American, 37,151 (6%) Asian/Pacific Islanders, and 97,912 (15%) others. African-American women (adjusted odds ratio [aOR]: 1.05, 95% CI: 1.02-1.08) were more likely to have PAMCs compared with White women, and Asian women (aOR: 0.92, 95% CI: 0.89-0.95) were significantly less likely to have PAMCs compared with White women. On stratified analysis according to the system of care, equal odds of PAMCs among African-American women compared with White women were realized within direct care (aOR: 1.03, 95% CI: 1.00-1.07), whereas slightly higher odds among African-American persisted in purchased (aOR: 1.05, 95% CI: 1.01-1.10). CONCLUSION Higher occurrence of PAMCs among minority women sponsored by a universal health coverage was mitigated compared with White women. Protocol-based care as in the direct care system may help overcome health disparities.
Collapse
Affiliation(s)
- Anju Ranjit
- Department of Obstetrics and Gynecology, Howard University Hospital, Washington, District of Columbia
| | - Tomas Andriotti
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Cathaleen Madsen
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Tracey Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Barton Staat
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Catherine Witkop
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Sarah E Little
- Department of Obstetrics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Julian Robinson
- Department of Obstetrics, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
10
|
Frankel D, Banaag A, Madsen C, Koehlmoos T. Examining Racial Disparities in Diabetes Readmissions in the United States Military Health System. Mil Med 2020; 185:e1679-e1685. [PMID: 32633784 DOI: 10.1093/milmed/usaa153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Diabetes is one of the most common chronic conditions in the United States and has a cost burden over $120 billion per year. Readmissions following hospitalization for diabetes are common, particularly in minority patients, who experience greater rates of complications and lower quality healthcare compared to white patients. This study examines disparities in diabetes-related readmissions in the Military Health System, a universally insured, population of 9.5 million beneficiaries, who may receive care from military (direct care) or civilian (purchased care) facilities. METHODS The study identified a population of 7,605 adult diabetic patients admitted to the hospital in 2014. Diagnostic codes were used to identify hospital readmissions, and logistic regression was used to analyze associations among race, beneficiary status, patient or sponsor's rank, and readmissions at 30, 60, and 90 days. RESULTS A total of 239 direct care patients and 545 purchased care patients were included in our analyses. After adjusting for age and sex, we found no significant difference in readmission rates for black versus white patients; however, we found a statistically significant increase in the likelihood for readmission of Native American/Alaskan Native patients compared to white patients, which persisted in direct care at 60 days (adjusted odds ratio [AOR] 11.51, 95% CI 1.11-119.41) and 90 days (AOR 18.42, 95% CI 1.78-190.73), and in purchased care at 90 days (AOR 4.54, 95% CI 1.31-15.74). CONCLUSION Our findings suggest that universal access to healthcare alleviates disparities for black patients, while Native America/Alaskan Native populations may still be at risk of disparities associated with readmissions among diabetic patients in both the closed direct care system and the civilian fee for service purchased care system.
Collapse
Affiliation(s)
- Dianne Frankel
- Uniformed Services University of the Health Sciences; 4301 Jones Bridge Road, Bethesda, MD, 20814
| | - Amanda Banaag
- Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD, 20817
| | - Cathaleen Madsen
- Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD, 20817
| | - Tracey Koehlmoos
- Uniformed Services University of the Health Sciences; 4301 Jones Bridge Road, Bethesda, MD, 20814
| |
Collapse
|
11
|
Madsen C, Banaag A, Koehlmoos TP. Trends in Use of Acupuncture During Pregnancy for the Military Health System, 2006-2016. Med Acupunct 2019; 31:366-371. [PMID: 31871524 DOI: 10.1089/acu.2019.1376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: Acupuncture is recognized as safe for use in pregnancy when correctly performed and has been provided at military healthcare facilities since 2005. Previous research identified a number of pregnant patients receiving acupuncture within the Military Health System (MHS). This study was conducted to describe trends in usage from 2006 to 2016 including patient and provider characteristics. Materials and Methods: This study utilized TRICARE claims from the MHS Data Repository (MDR). Analysis was performed through the MDR for women ages 18 years and older, who had acupuncture treatments at military treatment facilities related to pregnancy, from 2006 to 2016. Descriptive statistics were collected on patient demographics, clinic types and provider specialties, major diagnostic categories associated with acupuncture, number of visits per patient, and utilization over time. Results: Less than 0.3% of pregnant women in the MHS received acupuncture. The greatest usage was among patients who were white, ages 25-34, dependents of active duty personnel, and in the Army service. The most common diagnoses were for musculoskeletal system and connective tissue disorders (41.9%). Approximately 79% of care was delivered by physicians. The trend over time rose from 11 visits in 2006 to 130 visits in 2016. Conclusions: Provision of acupuncture in pregnancy grew ∼12-fold between 2006 and 2016, although usage remains low overall. This greater proportion of physician-provided care in pregnant women versus the general patient population may reflect a cautionary attitude toward use in pregnancy. This research is expected to inform discussions for people seeking to increase access to acupuncture during pregnancy.
Collapse
Affiliation(s)
- Cathaleen Madsen
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD
| | - Amanda Banaag
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD
| | - Tracey Pérez Koehlmoos
- Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine; Bethesda, MD
| |
Collapse
|
12
|
Arvizo C, Garrison E. Diversity and inclusion: the role of unconscious bias on patient care, health outcomes and the workforce in obstetrics and gynaecology. Curr Opin Obstet Gynecol 2019; 31:356-62. [DOI: 10.1097/gco.0000000000000566] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
13
|
Madenci AL, Wolf LL, Jiang W, Koehlmoos TP, Learn PA, Haider AH, Smink DS. Contemporary Factors Associated with the Use of Laparoscopy for Inguinal Hernia Repair Among Department of Defense Beneficiaries. Mil Med 2018; 183:e420-e426. [PMID: 29635522 DOI: 10.1093/milmed/usy029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/29/2017] [Accepted: 02/08/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The factors that contribute to variation in utilization of laparoscopic inguinal hernia repair are unknown. We sought to determine the current usage patterns of laparoscopic and open surgery in the elective repair of uncomplicated unilateral inguinal hernia in a large population with universal health care coverage comprised of Department of Defense (DoD) beneficiaries. MATERIALS AND METHODS The DoD Military Health System Data Repository (MDR) tracks health care delivered to a universally insured population of active/reserve/retired members of the U.S. Armed Services and their dependents. The MDR was queried for elective unilateral inguinal hernia repair among adult patients between 2008 and 2014. The primary outcome was laparoscopic (vs. open) approach to hernia repair. We conducted univariable and multivariable analyses of patient- and systems-level factors associated with approach to inguinal hernia repair. This research was approved by our institutional review board prior to commencement of the study and need for informed consent was waived given the design of this study. RESULTS Among 37,742 elective uncomplicated unilateral inguinal hernia repairs, 35% (n = 13,114) were performed laparoscopically. In 2014, 40% of inguinal hernia repairs were performed laparoscopically, compared with 27% of repairs in 2008 (P < 0.01). In multivariable analysis, laparoscopic hernia repair was more likely for male patients (OR = 1.38, 95% CI = 1.23-1.54, P < 0.01), military (vs. civilian) institutions (OR = 1.34, 95% CI = 1.28-1.41, P < 0.01), active-duty officers (vs. active-duty enlisted; OR = 1.21, 95% CI = 1.12-1.30, P < 0.01), and more recent year of surgery (P < 0.01). Laparoscopic repair was significantly less likely among patients with greater than one comorbidity (vs. none; OR = 0.68, 95% CI = 0.61-0.76, P < 0.01). CONCLUSION In a large, universally insured population of military service members and their dependents, laparoscopic inguinal repair is increasingly used and was preferred over open repair for younger, healthier, active-duty patients and those treated within the military (vs. non-military) care system.
Collapse
Affiliation(s)
- Arin L Madenci
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA.,Center for Surgery and Public Health, Brigham and Women's Hospital and Harvard Medical School, One Brigham Circle, 1620 Tremont St, Boston, MA
| | - Lindsey L Wolf
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA.,Center for Surgery and Public Health, Brigham and Women's Hospital and Harvard Medical School, One Brigham Circle, 1620 Tremont St, Boston, MA
| | - Wei Jiang
- Center for Surgery and Public Health, Brigham and Women's Hospital and Harvard Medical School, One Brigham Circle, 1620 Tremont St, Boston, MA
| | - Tracey P Koehlmoos
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD
| | - Peter A Learn
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD
| | - Adil H Haider
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA.,Center for Surgery and Public Health, Brigham and Women's Hospital and Harvard Medical School, One Brigham Circle, 1620 Tremont St, Boston, MA
| | - Douglas S Smink
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA.,Center for Surgery and Public Health, Brigham and Women's Hospital and Harvard Medical School, One Brigham Circle, 1620 Tremont St, Boston, MA
| |
Collapse
|
14
|
Ranjit A, Jiang W, Zhan T, Kimsey L, Staat B, Witkop CT, Little SE, Haider AH, Robinson JN. Intrapartum obstetric care in the United States military: Comparison of military and civilian care systems within TRICARE. Birth 2017; 44:337-344. [PMID: 28833512 DOI: 10.1111/birt.12298] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/09/2017] [Accepted: 06/09/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Expectant mothers who are beneficiaries of TRICARE (universal insurance to United States Armed Services members and their dependents) can choose to receive care within direct (salary-based) or purchased (fee-for-service) care systems. We sought to compare frequency of intrapartum obstetric procedures and outcomes such as severe acute maternal morbidity (SAMM) and common postpartum complications between direct and purchased care systems within TRICARE. METHODS TRICARE (2006-2010) claims data were used to identify deliveries. Patient demographics, frequency of types of delivery (noninstrumental vaginal, cesarean, and instrumental vaginal), comorbid conditions, SAMM, and common postpartum complications were compared between the two systems of care. Multivariable models adjusted for patient clinical/demographic factors determined the odds of common complications and SAMM complications in purchased care compared with direct care. RESULTS A total of 440 138 deliveries were identified. Compared with direct care, purchased care had higher frequency (30.9% vs 25.8%, P<.001) and higher adjusted odds (aOR 1.37 [CI 1.34-1.38]) of cesarean delivery. In stratified analysis by mode of delivery, purchased care had lower odds of common complications for all modes of delivery (aOR[CI]:noninstrumental vaginal: 0.72 [0.71-0.74], cesarean: 0.71 [0.68-0.75], instrumental vaginal: 0.64 [0.60-0.68]) than direct care. However, purchased care had higher odds of SAMM complications for cesarean delivery (aOR 1.31 [CI 1.19-1.44]) compared with direct care. CONCLUSION Direct care has a higher vaginal delivery rate but also a higher rate of common complications compared with purchased care. Study of direct and purchased care systems in TRICARE may have potential use as a surrogate for comparing obstetric care between salary-based systems and fee-for-service systems in the United States.
Collapse
Affiliation(s)
- Anju Ranjit
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Medicine and Harvard School of Public Health, Boston, MA, USA
| | - Wei Jiang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Medicine and Harvard School of Public Health, Boston, MA, USA
| | - Tiannan Zhan
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Medicine and Harvard School of Public Health, Boston, MA, USA
| | - Linda Kimsey
- Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA, USA
| | - Bart Staat
- Department of Obstetrics and Gynecology, Uniformed Health Services University, Bethesda, MD, USA
| | - Catherine T Witkop
- Department of Preventive Medicine and Biostatistics, Uniformed Health Services University, Bethesda, MD, USA
| | - Sarah E Little
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Medicine and Harvard School of Public Health, Boston, MA, USA
| | - Julian N Robinson
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
15
|
Ranjit A, Sharma M, Romano A, Jiang W, Staat B, Koehlmoos T, Haider AH, Little SE, Witkop CT, Robinson JN, Cohen SL. Does Universal Insurance Mitigate Racial Differences in Minimally Invasive Hysterectomy? J Minim Invasive Gynecol 2017; 24:790-796. [DOI: 10.1016/j.jmig.2017.03.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
|