Rate of Emergency Lower Extremity Amputations in the United States Among Medicare Beneficiaries

OBJECTIVE

To determine the rate of emergency versus elective lower extremity amputations in the United States.

BACKGROUND

Lower extremity amputation is a common endpoint for patients with poorly controlled diabetes and multilevel peripheral vascular disease. Although the procedure is ideally performed electively, patients with limited access may present later and require an emergency operation. To what extent rates of emergency amputation for lower extremities vary across the United States is unknown.

METHODS

Evaluation of Medicare beneficiaries who underwent lower extremity amputation between 2015 and 2020. The rate was determined for each zip code and placed into rank order from lowest to highest rate. We merged each beneficiary's place of residence and location of care with the American Hospital Association Annual Survey using Google Maps Application Programming Interface to determine the travel distance for patients to undergo their procedure.

RESULTS

Of 233,084 patients, 66.3% (154,597) were men, 69.8% (162,786) were White. The average age (SD) was 74 years (8). There was wide variation in rates of emergency lower extremity amputation. The lowest quintile of zip codes demonstrated an emergency amputation rate of 3.7%, whereas the highest quintile demonstrated 90%. The median travel distance in the lowest emergency surgery rate quintile was 34.6 miles compared with 10.5 miles in the highest quintile of emergency surgery ( P < 0.001).

CONCLUSIONS

There is wide variation in the rate of emergency lower extremity amputations among Medicare beneficiaries, suggesting variable access to essential vascular care. Travel distance and rate of amputation have an inverse relationship, suggesting that barriers other than travel distance are playing a role.

Health Insurance Status and Unplanned Surgery for Access-Sensitive Surgical Conditions

Importance

Access-sensitive surgical conditions, such as abdominal aortic aneurysm, ventral hernia, and colon cancer, are ideally treated with elective surgery, but when left untreated have a natural history requiring an unplanned operation. Patients' health insurance status may be a barrier to receiving timely elective care, which may be associated with higher rates of unplanned surgery and worse outcomes.

Objective

To evaluate the association between patients' insurance status and rates of unplanned surgery for these 3 access-sensitive surgical conditions and postoperative outcomes.

Design, Setting, and Participants

This cross-sectional cohort study examined a geographically broad patient sample from the Healthcare Cost and Utilization Project State Inpatient Databases, including data from 8 states (Arizona, Colorado, Florida, Kentucky, Maryland, North Carolina, Washington, and Wisconsin). Participants were younger than 65 years who underwent abdominal aortic aneurysm repair, ventral hernia repair, or colectomy for colon cancer between 2016 and 2020. Patients were stratified into groups by insurance status. Data were analyzed from June 1 to July 1, 2023.

Exposure

Health insurance status (private insurance, Medicaid, or no insurance).

Main Outcomes and Measures

The primary outcome was the rate of unplanned surgery for these 3 access-sensitive conditions. Secondary outcomes were rates of postoperative outcomes including inpatient mortality, any hospital complications, serious complications (a complication with a hospital length of stay longer than the 75th percentile for that procedure), and hospital length of stay.

Results

The study included 146 609 patients (mean [SD] age, 50.9 [10.3] years; 73 871 females [50.4%]). A total of 89 018 patients (60.7%) underwent elective surgery while 57 591 (39.3%) underwent unplanned surgery. Unplanned surgery rates varied significantly across insurance types (33.14% for patients with private insurance, 51.46% for those with Medicaid, and 72.60% for those without insurance; P < .001). Compared with patients with private insurance, patients without insurance had higher rates of inpatient mortality (1.29% [95% CI, 1.04%-1.54%] vs 0.61% [0.57%-0.66%]; P < .001), higher rates of any complications (19.19% [95% CI, 18.33%-20.05%] vs 12.27% [95% CI, 12.07%-12.47%]; P < .001), and longer hospital stays (7.27 [95% CI, 7.09-7.44] days vs 5.56 [95% CI, 5.53-5.60] days, P < .001).

Conclusions and Relevance

Findings of this cohort study suggest that uninsured patients more often undergo unplanned surgery for conditions that can be treated electively, with worse outcomes and longer hospital stays compared with their counterparts with private health insurance. As efforts are made to improve insurance coverage, tracking elective vs unplanned surgery rates for access-sensitive surgical conditions may be a useful measure to assess progress.

Higher Rates Of Emergency Surgery, Serious Complications, And Readmissions In Primary Care Shortage Areas, 2015-19

Primary care physicians are often the first to screen and identify patients with access-sensitive surgical conditions that should be treated electively. These conditions require surgery that is preferably planned (elective), but, when access is limited, treatment may be delayed and worsening symptoms lead to emergency surgery (for example, colectomy for cancer, abdominal aortic aneurysm repair, and incisional hernia repair). We evaluated the rates of elective versus emergency surgery for patients with three access-sensitive surgical conditions living in primary care Health Professional Shortage Areas during 2015-19. Medicare beneficiaries in more severe primary care shortage areas had higher rates of emergency surgery compared with rates in the least severe shortage areas (37.8 percent versus 29.9 percent). They were also more likely to have serious complications (14.9 percent versus 11.7 percent) and readmissions (15.7 percent versus 13.5 percent). When we accounted for areas with a shortage of surgeons, the findings were similar. Taken together, these findings suggest that residents of areas with greater primary care workforce shortages may also face challenges in accessing elective surgical care. As policy makers consider investing in Health Professional Shortage Areas, our findings underscore the importance of primary care access to a broader range of services.

Cdc73 protects Notch-induced T-cell leukemia cells from DNA damage and mitochondrial stress

ABSTRACT

Activated Notch signaling is highly prevalent in T-cell acute lymphoblastic leukemia (T-ALL), but pan-Notch inhibitors showed excessive toxicity in clinical trials. To find alternative ways to target Notch signals, we investigated cell division cycle 73 (Cdc73), which is a Notch cofactor and key component of the RNA polymerase-associated transcriptional machinery, an emerging target in T-ALL. Although we confirmed previous work that CDC73 interacts with NOTCH1, we also found that the interaction in T-ALL was context-dependent and facilitated by the transcription factor ETS1. Using mouse models, we showed that Cdc73 is important for Notch-induced T-cell development and T-ALL maintenance. Mechanistically, chromatin and nascent gene expression profiling showed that Cdc73 intersects with Ets1 and Notch at chromatin within enhancers to activate expression of known T-ALL oncogenes through its enhancer functions. Cdc73 also intersects with these factors within promoters to activate transcription of genes that are important for DNA repair and oxidative phosphorylation through its gene body functions. Consistently, Cdc73 deletion induced DNA damage and apoptosis and impaired mitochondrial function. The CDC73-induced DNA repair expression program co-opted by NOTCH1 is more highly expressed in T-ALL than in any other cancer. These data suggest that Cdc73 might induce a gene expression program that was eventually intersected and hijacked by oncogenic Notch to augment proliferation and mitigate the genotoxic and metabolic stresses of elevated Notch signaling. Our report supports studying factors such as CDC73 that intersect with Notch to derive a basic scientific understanding on how to combat Notch-dependent cancers without directly targeting the Notch complex.

Association of Health Professional Shortage Area Hospital Designation With Surgical Outcomes and Expenditures Among Medicare Beneficiaries

OBJECTIVE

To compare surgical outcomes and expenditures at hospitals located in Health Professional Shortage Areas to nonshortage area designated hospitals among Medicare beneficiaries.

BACKGROUND

More than a quarter of Americans live in federally designated Health Professional Shortage Areas. Although there is growing concern that medical outcomes may be worse, far less is known about hospitals providing surgical care in these areas.

METHODS

Cross-sectional retrospective study from 2014 to 2018 of 842,787 Medicare beneficiary patient admissions to hospitals with and without Health Professional Shortage Area designations for common operations including appendectomy, cholecystectomy, colectomy, and hernia repair. We assessed risk-adjusted outcomes using multivariable logistic regression accounting for patient factors, admission type, and year were compared for each of the 4 operations. Hospital expenditures were price-standardized, risk-adjusted 30-day surgical episode payments. Primary outcome measures included 30-day mortality, hospital readmissions, and 30-day surgical episode payments.

RESULTS

Patients (mean age=75.6 years, males=44.4%) undergoing common surgical procedures in shortage area hospitals were less likely to be White (84.6% vs 88.4%, P <0.001) and less likely to have≥2 Elixhauser comorbidities (75.5% vs 78.2%, P <0.001). Patients undergoing surgery at Health Professional Shortage Area hospitals had lower risk-adjusted rates of 30-day mortality (6.05% vs 6.69%, odds ratio=0.90, CI, 0.90-0.91, P <0.001) and readmission (14.99% vs 15.74%, odds ratio=0.94, CI, 0.94-0.95, P <0.001). Medicare expenditures at Health Professional Shortage Area hospitals were also lower than nonshortage designated hospitals ($28,517 vs $29,685, difference= -$1168, P <0.001).

CONCLUSIONS

Patients presenting to Health Professional Shortage Area hospitals obtain safe care for common surgical procedures without evidence of higher expenditures among Medicare beneficiaries. These findings should be taken into account as current legislative proposals to increase funding for care in these underserved communities are considered.

Surgical Procedures at Critical Access Hospitals Within Hospital Networks

OBJECTIVE

To compare surgical outcomes and expenditures at critical access hospitals that do versus do not participate in a hospital network among Medicare beneficiaries.

BACKGROUND

Critical access hospitals provide essential care to more than 80 million Americans. These hospitals, often rural, are located more than 35 miles away from another hospital and are required to maintain patient transfer agreements with other facilities capable of providing higher levels of care. Some critical access hospitals have gone further to formally participate in a hospital network.

METHODS

This was a cross-sectional retrospective study from 2014 to 2018 comparing 16,128 Medicare beneficiary admissions for appendectomy, cholecystectomy, colectomy, or hernia repair at critical access hospitals that do versus do not participate in a hospital network. Thirty-day mortality and readmissions were risk adjusted using multivariable logistic regression accounting for patient and hospital factors. Price-standardized, risk-adjusted Medicare expenditures were compared for the 30-day total episode payments consisting of index hospitalization, physician services, readmissions, and postacute care payments.

RESULTS

Beneficiaries (average age = 75.7 years, SD = 7.4) who obtained care at critical access hospitals in a hospital network were more likely to carry ≥2 Elixhauser comorbidities (68.7% vs. 62.8%, P < 0.001). Rates of 30-day mortality were higher at critical access hospitals in a hospital network (4.30% vs. 3.81%, OR = 1.11, P < 0.001). Similarly, readmission rates were higher at critical access hospitals that were in a hospital network (15.13% vs. 14.34%, OR = 1.06, P < 0.001). Additionally, total episode payments were found to be $960 higher per patient at critical access hospitals that were in a hospital network ($23,878 vs. $22,918, P < 0.001).

CONCLUSIONS

Critical access hospitals within hospital networks provided care to more medically complex patients and were associated with worse clinical outcomes and higher costs among Medicare beneficiaries undergoing common general surgery operations.

High-risk surgery among Medicare beneficiaries living in health professional shortage areas

PURPOSE

Americans who reside in health professional shortage areas currently have less than half of the needed physician workforce. While the shortage designation has been associated with poor outcomes for chronic medical conditions, far less is known about outcomes after high-risk surgical procedures.

METHODS

We performed a retrospective review of Medicare beneficiaries living in health professional shortage areas and nonshortage areas who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, esophagectomy, liver resection, pancreatectomy, or rectal resection between 2014 and 2018. Risk-adjusted multivariable logistic regression was used to determine whether rates of postoperative complications and 30-day mortality differed between patient cohorts. Beneficiary and hospital ZIP codes were used to quantify travel time to obtain care.

FINDINGS

Compared with patients living in nonshortage areas, patients living in health professional shortage areas traveled longer (median 60.0 vs 28.0 minutes, P<.001). There were no differences in risk-adjusted rates of complications (28.5% vs 28.6%, OR = 1.00, 95% CI 1.00-1.00, P = .59) and small differences in rates of 30-day mortality (4.2% vs 4.4%, OR = 0.95, 95% CI 0.95-0.95, P<.001) between beneficiaries living in shortage areas versus those not in shortage areas, respectively.

CONCLUSIONS

Patients living in health professional shortage area undergoing high-risk surgery traveled more than 2 times longer for their care to obtain similar outcomes. While reassuring for clinical outcomes, additional efforts may be needed to mitigate the travel burden experienced by shortage area patients.

Hospital-Level Segregation Among Medicare Beneficiaries Undergoing Lung Cancer Resection

BACKGROUND

Recent research has raised concern that health care segregation, the high concentration of racial groups within a subset of hospitals, is a key contributor to persistent disparities in surgical care. However, to date the extent and effect of hospital level segregation among patients undergoing resection for lung cancer remains unclear.

METHODS

We used 100% Medicare fee-for-service claims to evaluate the degree of hospital-level racial segregation for patients undergoing resection for lung cancer between 2014 and 2018. Hospitals serving a high volume of minority patients were defined as the top decile of hospitals by volume of racial and ethnic minority beneficiaries served. Multivariable logistic regression analysis was used to compare surgical outcomes between hospitals serving high vs low volumes of minority patients.

RESULTS

A total of 122,943 patients were included, with racial/ethnic composition of 360 American Indian or Native American (0.3%), 2077 Asian or Pacific Islander (1.7%), 1146 Hispanic or Latino (0.9%), 8707 non-Hispanic Black (7.1%), and 108,665 non-Hispanic White patients. Overall, 31.6%, 15.9%, 15.0%, and 7.8% of all hospitals performed 90% of lung cancer resection for Black, Asian, Hispanic, and Native American patients, respectively. Hospitals performing higher volumes of operations for racial and ethnic minorities had higher mortality (3.9% vs 3.1%; odds ratio [OR], 1.19; 95% CI, 1.15-1.23; P < .001), complications (18.1% vs 15.9%; OR, 1.17; 95% CI, 1.14-1.19; P < .001), and readmissions (11.7% vs 11.2%; OR, 1.04; 95% CI, 1.02-1.05; P < .001) for resections for lung cancer.

CONCLUSIONS

Our findings suggest that a small proportion of hospitals provide a disproportionate amount of surgical care for racial and ethnic minorities with lung cancer with inferior surgical outcomes.

Disparities in unplanned surgery amongst medicare beneficiaries

BACKGROUND

While significant efforts have been made to understand surgical disparities for procedures that are performed in either the elective or unplanned settings, far less is known about procedures performed in both settings.

METHODS

Cross-sectional study of 1,135,743 Medicare beneficiaries undergoing incisional hernia repair, colectomy, or abdominal aortic aneurysm repair between 2014 and 2018. Risk-adjusted outcomes were assessed using multivariable logistic regression.

RESULTS

Compared to White beneficiaries, unplanned surgery rates were higher for Black (44.0%vs38.8%, OR = 1.29,p < 0.001) and Asian beneficiaries(40.4%vs38.8%,OR = 1.09,p < 0.001). While there were minimal differences in 30-day mortality for elective procedures, unplanned procedures demonstrated wider disparities (Black vs White 12.4%vs11.3%,OR = 1.11,p < 0.001; Asian vs White 13.2%vs11.3%,OR = 1.18,p < 0.001). Similar patterns were observed for readmissions.

CONCLUSIONS

Unplanned procedures are more common and demonstrate wider disparities in outcomes among minority Medicare beneficiaries. Reducing unplanned surgery rates among these groups may be an effective strategy to limit overall disparities in postoperative outcomes.

Association Between California's State Insurance Gender Nondiscrimination Act and Utilization of Gender-Affirming Surgery

Importance

Gender-affirming surgery is often beneficial for gender-diverse or -dysphoric patients. Access to gender-affirming surgery is often limited through restrictive legislation and insurance policies.

Objective

To investigate the association between California's 2013 implementation of the Insurance Gender Nondiscrimination Act, which prohibits insurers and health plans from limiting benefits based on a patient's sex, gender, gender identity, or gender expression, and utilization of gender-affirming surgery among California residents.

Design, Setting, and Participants

Population epidemiology study of transgender and gender-diverse patients undergoing gender-affirming surgery (facial, chest, and genital surgery) between 2005 and 2019. Utilization of gender-affirming surgery in California before and after implementation of the Insurance Gender Nondiscrimination Act in July 2013 was compared with utilization in Washington and Arizona, control states chosen because of geographic similarity and because they expanded Medicaid on the same date as California-January 1, 2014. The date of last follow-up was December 31, 2019.

Exposures

California's Insurance Gender Nondiscrimination Act, implemented on July 9, 2013.

Main Outcomes and Measures

Receipt of gender-affirming surgery, defined as undergoing at least 1 facial, chest, or genital procedure.

Results

A total of 25 252 patients (California: n = 17 934 [71%]; control: n = 7328 [29%]) had a diagnosis of gender dysphoria. Median ages were 34.0 years in California (with or without gender-affirming surgery), 39 years (IQR, 28-49 years) among those undergoing gender-affirming surgery in control states, and 36 years (IQR, 22-56 years) among those not undergoing gender-affirming surgery in control states. Patients underwent at least 1 gender-affirming surgery within the study period in 2918 (11.6%) admissions-2715 (15.1%) in California vs 203 (2.8%) in control states. There was a statistically significant increase in gender-affirming surgery in the third quarter of July 2013 in California vs control states, coinciding with the timing of the Insurance Gender Nondiscrimination Act (P < .001). Implementation of the policy was associated with an absolute 12.1% (95% CI, 10.3%-13.9%; P < .001) increase in the probability of undergoing gender-affirming surgery in California vs control states observed in the subset of insured patients (13.4% [95% CI, 11.5%-15.4%]; P < .001) but not self-pay patients (-22.6% [95% CI, -32.8% to -12.5%]; P < .001).

Conclusions and Relevance

Implementation in California of its Insurance Gender Nondiscrimination Act was associated with a significant increase in utilization of gender-affirming surgery in California compared with the control states Washington and Arizona. These data might inform state legislative efforts to craft policies preventing discrimination in health coverage for state residents, including transgender and gender-diverse patients.

Cdc73 protects Notch-induced T-cell leukemia cells from DNA damage and mitochondrial stress

Activated Notch signaling is highly prevalent in T-cell acute lymphoblastic leukemia (T-ALL) but pan-Notch inhibitors were toxic in clinical trials. To find alternative ways to target Notch signals, we investigated Cell division cycle 73 (Cdc73), which is a Notch cofactor and component of transcriptional machinery, a potential target in T-ALL. While we confirmed previous work that CDC73 interacts with NOTCH1, we also found that the interaction in T-ALL was context-dependent and facilitated by the lymphoid transcription factor ETS1. Using mouse models, we showed that Cdc73 is important for Notch-induced T-cell development and T-ALL maintenance. Mechanistically, Cdc73, Ets1, and Notch intersect chromatin at promoters and enhancers to activate oncogenes and genes that are important for DNA repair and oxidative phosphorylation. Consistently, Cdc73 deletion in T-ALL cells induced DNA damage and impaired mitochondrial function. Our data suggests that Cdc73 might promote a gene expression program that was eventually intersected by Notch to mitigate the genotoxic and metabolic stresses of elevated Notch signaling. We also provide mechanistic support for testing inhibitors of DNA repair, oxidative phosphorylation, and transcriptional machinery. Inhibiting pathways like Cdc73 that intersect with Notch at chromatin might constitute a strategy to weaken Notch signals without directly targeting the Notch complex.

Social Vulnerability and Emergency General Surgery among Medicare Beneficiaries

BACKGROUND

Although the Social Vulnerability Index (SVI) was created to identify vulnerable populations after unexpected natural disasters, its ability to identify similar groups of patients undergoing unexpected emergency surgical procedures is unknown. We sought to examine the association between SVI and outcomes after emergency general surgery.

STUDY DESIGN

This study is a cross-sectional review of 887,193 Medicare beneficiaries who underwent 1 of 4 common emergency general surgery procedures (appendectomy, cholecystectomy, colectomy, and ventral hernia repair) performed in the urgent or emergent setting between 2014 and 2018. These data were merged with the SVI at the census-track level of residence. Risk-adjusted outcomes (30-day mortality, serious complications, readmission) were evaluated using a logistic regression model accounting for age, sex, comorbidity, year, procedure type, and hospital characteristics between high and low social vulnerability quintiles and within the 4 SVI subthemes (socioeconomic status; household composition and disability; minority status and language; and housing type and transportation).

RESULTS

Compared with beneficiaries with low social vulnerability, Medicare beneficiaries living in areas of high social vulnerability experienced higher rates of 30-day mortality (8.56% vs 8.08%; adjusted odds ratio 1.07; p < 0.001), serious complications (20.71% vs 18.40%; adjusted odds ratio 1.17; p < 0.001), and readmissions (16.09% vs 15.03%; adjusted odds ratio 1.08; p < 0.001). This pattern of differential outcomes was present in subgroup analysis of all 4 SVI subthemes but was greatest in the socioeconomic status and household composition and disability subthemes.

CONCLUSIONS

National efforts to support patients with high social vulnerability from natural disasters may be well aligned with efforts to identify communities that are particularly vulnerable to worse postoperative outcomes after emergency general surgery. Policies targeting structural barriers related to household composition and socioeconomic status may help alleviate these disparities.

Association of Coded Housing Instability and Hospitalization in the US

IMPORTANCE

Housing instability and other social determinants of health are increasingly being documented by clinicians. The most common reasons for hospitalization among patients with coded housing instability, however, are not well understood.

OBJECTIVE

To compare the most common reasons for hospitalization among patients with and without coded housing instability.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, retrospective study identified hospitalizations of patients between age 18 and 99 years using the 2017 to 2019 National Inpatient Sample. Data were analyzed from May to September 2022.

EXPOSURES

Housing instability was operationalized using 5 International Classification of Diseases, 10th Revision, Social Determinants of Health Z-Codes addressing problems related to housing: homelessness; inadequate housing; discord with neighbors, lodgers, and landlords; residential institution problems; and other related problems.

MAIN OUTCOMES AND MEASURES

The primary outcome of interest was reason for inpatient admission. Bivariate comparisons of patient characteristics, primary diagnoses, length of stay, and hospitalization costs among patients with and without coded housing instability were performed.

RESULTS

Among the 87 348 604 hospitalizations analyzed, the mean (SD) age was 58 (20) years and patients were more likely to be women (50 174 117 [57.4%]) and White (58 763 014 [67.3%]). Housing instability was coded for 945 090 hospitalizations. Hospitalized patients with housing instability, compared with those without instability, were more likely to be men (668 255 patients with coded instability [70.7%] vs 36 506 229 patients without [42.3%]; P < .001), younger (mean [SD] age 45.5 [14.0] vs 58.4 [20.2] years), Black (235 355 patients [24.9%] vs 12 929 158 patients [15.0%]), Medicaid beneficiaries (521 555 patients [55.2%] vs 15 541 175 patients [18.0%]), uninsured (117 375 patients [12.4%] vs 3 476 841 patients [4.0%]), and discharged against medical advice (28 890 patients [8.4%] vs 451 855 patients [1.6%]). The most common reason for hospitalization among patients with coded housing instability was mental, behavioral, and neurodevelopmental disorders (475 575 patients [50.3%]), which cost a total of $3.5 billion. Other common reasons included injury (69 270 patients [7.3%]) and circulatory system diseases (64 700 patients [6.8%]). Coded housing instability was also significantly associated with longer mean (SD) hospital stays (6.7 [.06] vs 4.8 [.01] days) and a cost of $9.3 billion. Hospitalized patients with housing instability had 18.6 times greater odds of having a primary diagnosis of mental, behavioral, and neurodevelopmental disorders (475 575 patients [50.3%] vs 4 470 675 patients [5.2%]; odds ratio, 18.56; 95% CI, 17.86 to 19.29).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, hospitalizations among patients with coded housing instability had higher admission rates for mental, behavioral, and neurodevelopmental disorders, longer stays, and increased costs. Findings suggest that efforts to improve housing instability, mental and behavioral health, and inpatient hospital utilization across multiple sectors may find areas for synergistic collaboration.

Emergency Surgery Rates Among Medicare Beneficiaries With Access Sensitive Surgical Conditions

INTRODUCTION

Access sensitive surgical conditions should be treated electively with optimal access but result in emergency operations when access is limited. However, the rates of emergency procedures for these conditions are unknown.

METHODS

Cross-sectional retrospective review of Medicare beneficiaries who underwent access sensitive surgical procedures (abdominal aortic aneurysm repair, colectomy for colorectal cancer, or incisional hernia repair) between 2014 and 2018. Risk-adjusted outcomes using a multivariable logistical regression that adjusted for patient factors (age, sex, race, and Elixhauser comorbidities), hospital characteristics (ownership, size, geographic region, surgical volume) and type of operation were compared between planned and emergency (urgent and emergent) surgical procedures. Outcome measures were rates of emergency procedures as well as associated postoperative outcomes.

RESULTS

Of the 744,818 Medicare beneficiaries undergoing access sensitive surgical procedures, 259,541 (34.9%) were done in the emergency setting. Risk-adjusted rates of emergency surgery varied widely across hospital service areas from 23.28% (lowest decile) to 54.88% (highest decile) (Odds Ratio 4.74; P < 0.001). Emergency procedures were associated with significantly higher rates of 30-d mortality (8.15% versus 3.65%, P < 0.001) and readmissions (16.28% versus 12.88%, P < 0.001) compared to elective procedures. Sensitivity analysis with younger and healthier beneficiaries demonstrated persistently high rates (23.3%) of emergency surgery with wide regional variation and worse patient outcomes.

CONCLUSIONS

Emergency surgery for access sensitive surgical conditions is extremely common and varied almost fivefold across United States hospital service areas. This suggests there are opportunities to improve access for these common surgical conditions.

Neighborhood deprivation and Medicare expenditures for common surgical procedures

INTRODUCTION

The Center of Medicare and Medicaid Services valued based payments for inpatient surgical hospitalizations are adjusted for clinical but not social risk factors. While research has shown that social risk is associated with worse surgical patient outcomes, it is unknown if inpatient surgical episode Medicare payments are affected by social risk factors.

METHODS

Retrospective review of Medicare beneficiaries, age 65-99, undergoing appendectomy, colectomy, hernia repair, or cholecystectomy between 2014 and 2018. Neighborhood deprivation measured by Area Deprivation Index for beneficiary census tract. We evaluated Medicare payments for a total episode of surgical care comprised of index hospitalization, physician fees, post-acute care, and readmission by beneficiary neighborhood deprivation.

RESULTS

A total of 809,059 patients (Women, 56.0%) and mean (SD) age of 75.7 (7.4 years were included. A total of 145,351 beneficiaries lived in the least deprived neighborhoods and 134,188 who lived in the most deprived neighborhoods. Total surgical episode spending was $2654 higher among beneficiaries from the most deprived neighborhoods compared to those from the least after risk adjustment for clinical and hospital factors. These differences were driven in part by higher rates of readmissions (12.9% vs 10.8%, P < 0.001) and post-acute care (67.8% vs. 61.2%, P < 0.001) among beneficiaries living in the most deprived neighborhoods.

CONCLUSION

These findings suggest that value-based payment models with inclusion of social risk adjustment may be needed for surgical cohorts. Moreover, efforts focused on investing in deprived communities may be aligned with surgical quality improvement.

Social Vulnerability And Outcomes For Access-Sensitive Surgical Conditions Among Medicare Beneficiaries

Concerns have been raised over wide variation in rates of unplanned (emergency or urgent) surgery for access-sensitive surgical conditions-diagnoses requiring surgery that preferably is planned (elective) but, when access is limited, may be delayed until worsening symptoms require riskier and costlier unplanned surgery. Yet little is known about geographic and community-level factors that may increase the likelihood of unplanned surgery with adverse outcomes. We examined the relationship between community-level social vulnerability and rates of unplanned surgery for three access-sensitive conditions in 2014-18 among fee-for-service Medicare beneficiaries ages 65-99. Compared with patients from communities with the lowest social vulnerability, those from communities with the highest vulnerability were more likely, overall, to undergo unplanned surgery (36.2 percent versus 33.5 percent). They were also more likely to experience worse outcomes largely attributable to differential rates of unplanned surgery, including higher rates of mortality (5.4 percent versus 5.0 percent) and additional surgery within thirty days (19.6 percent versus 18.1 percent). Our findings suggest that policy addressing community-level social vulnerability may mitigate the observed differences in surgical procedures and outcomes for access-sensitive conditions.

Combinatorial ETS1-dependent control of oncogenic NOTCH1 enhancers in T-cell leukemia

Notch activation is highly prevalent among cancers, in particular T-cell acute lymphoblastic leukemia (T-ALL). However, the use of pan-Notch inhibitors to treat cancers has been hampered by adverse effects, particularly intestinal toxicities. To circumvent this barrier in T-ALL, we aimed to inhibit ETS1, a developmentally important T-cell transcription factor previously shown to co-bind Notch response elements. Using complementary genetic approaches in mouse models, we show that ablation of Ets1 leads to strong Notch-mediated suppressive effects on T-cell development and leukemogenesis, but milder intestinal effects than pan-Notch inhibitors. Mechanistically, genome-wide chromatin profiling studies demonstrate that Ets1 inactivation impairs recruitment of multiple Notch-associated factors and Notch-dependent activation of transcriptional elements controlling major Notch-driven oncogenic effector pathways. These results uncover previously unrecognized hierarchical heterogeneity of Notch-controlled genes and points to Ets1-mediated enucleation of Notch-Rbpj transcriptional complexes as a target for developing specific anti-Notch therapies in T-ALL that circumvent the barriers of pan-Notch inhibition.