Hospital Safety-net Burden Research Articles

Failure to rescue after major abdominal surgery: The role of hospital safety net burden

BackgroundWe aimed to examine whether safety-net burden is a significant predictor of failure-to-rescue (FTR) after major abdominal surgery controlling for patient and hospital characteristics, including surgical volume. MethodsData were extracted from the 2007–2011 Nationwide Inpatient Sample. FTR was defined as mortality among patients experiencing major postoperative complications. Differences in rates of complications, mortality, and FTR across quartiles of safety-net burden were assessed with univariate analyses. Multilevel regression models were constructed to estimate the association between FTR and safety-net burden. ResultsAmong 238,645 patients, the incidence of perioperative complications, in-hospital mortality, and FTR were 33.7%, 4.4%, and 11.8%, respectively. All the outcomes significantly increased across the quartiles of safety-net burden. In the multilevel regression analyses, safety-net burden was a significant predictor of FTR after adjustment for patient and hospital characteristics, including hospital volume. ConclusionIncreasing hospital safety-net burden is associated with higher odds of FTR for major abdominal surgery.

How Safe Are Safety-Net Hospitals? Opportunities to Improve Outcomes for Vulnerable Patients Undergoing Hepatopancreaticobiliary Surgery

IntroductionSafety-net hospitals are critical to the US health system as they provide care to vulnerable patients. The effect of hospital safety-net burden on patient outcomes in hepatopancreaticobiliary (HPB) surgery was examined. MethodsDischarge data between 2004 and 2014 from the National Inpatient Sample were utilized. Hospitals with a safety-net burden were divided into tertiles: low (LBH) (< 13.6%), medium (MBH) (13.6–33.3%), and high (HBH) (> 33.3%). The association of hospital safety-net burden with complications, in-hospital mortality, never events, and costs were defined. ResultsNearly 5% of the analytic cohort (n = 65,032) had surgery at a HBH. Patients treated at HBH were younger (median age, HBH 55 years vs LBH 62 years; p < 0.001), black or Hispanic (HBH 40.5% vs LBH 12.7%; p < 0.001), and of lowest income quartile (HBH 38.4% vs LBH 19.6%; p < 0.001). One-third of patients at HBH experienced a complication compared with only a quarter of patients at LBH (p < 0.001). HBH had higher rates of in-hospital mortality (HBH 6.5% vs. LBH 2.8%; p < 0.001), never events (HBH 5.4% vs. LBH 1.4%; p < 0.001), and a higher cost of surgery (HBH $30,716 vs. LBH $28,054; p < 0.001). ConclusionPerioperative outcomes were worse at HBH, highlighting that efforts are needed to improve their delivery of care.

76 Hepatorenal Syndrome Carries the Highest Risk of In-Hospital Mortality Among Hospitalized Patients With Primary Biliary Cholangitis

INTRODUCTION: Primary biliary cholangitis (PBC) is an autoimmune and progressive cholestatic liver disease with significant morbidity and mortality. Hospitals with safety-net burden (SNB) provide an essential role to serving low-income and historically vulnerable populations. We aim to evaluate factors, including hospital SNB, associated with in-hospital mortality among hospitalizations with PBC. METHODS: Using the 2012–2014 National Inpatient Sample, we evaluated US adults hospitalized with PBC (using ICD-9 codes). Hospital SNB was defined as the percentage of hospitalizations among PBC with Medicaid or uninsured payer status per hospital, and was categorized into two groups: no SNB vs. any SNB. Between-group comparisons used chi-squared testing. Survey-weighted, adjusted multivariate logistic regression analysis was used to evaluate factors associated with in-hospital mortality. RESULTS: Among 7,364 hospitalizations with PBC (mean age 64.0 + 14.3y, 16.1% men, 70.3% non-Hispanic White), 65.3% were in no SNB and 34.7% were in low-high SNB hospitals. Crude in-hospital mortality was 4.15%, with no significant differences by hospital SNB. On adjusted regression, among the cirrhosis-related complications analyzed, the presence of ascites (OR 1.85, 95% CI 1.36–2.52, P &lt; 0.001), hepatic encephalopathy (OR 2.32, 95% CI 1.75–3.08, P &lt; 0.001) and hepatorenal syndrome (OR 7.58, 95% CI 5.12–11.2, P &lt; 0.001) resulted in higher odds of in-hospital mortality compared to those without the respective complication present. Additionally, hospitalizations at urban teaching hospitals also had a higher odds of in-hospital mortality compared to rural hospitals (OR: 2.04, 95% CI: 1.20–3.46, P = 0.01). CONCLUSION: Hospitalizations with PBC with concomitant cirrhosis-related complications had significantly higher odds of in-hospital mortality. Specifically, PBC hospitalizations with hepatorenal syndrome were 7.6 times more likely to die during hospitalization. Urban teaching hospitals also had higher in-hospital mortality compared to rural hospitals.

1236 Hospitals With Low-Medium Safety-Net Burden Incur the Highest Costs for Hospitalizations of U.S. Adults With Gastric Cancer

INTRODUCTION: Although gastric cancer is relatively rare in the U.S., diagnosis at an earlier stage is associated with improved treatment options and higher overall survival. Safety-net hospitals continue to bear the brunt of recent major healthcare coverage reforms. We aim to evaluate factors, including safety-net burden (SNB), associated with in-hospital mortality and inpatient costs among hospitalized adults with gastric cancer. METHODS: Using the 2012-2014 National Inpatient Sample, adult hospitalizations with gastric cancer were identified using ICD-9 codes. Hospital SNB was defined as percentage of hospitalizations with Medicaid or uninsured payer status per hospital, and categorized into three groups: none, low-medium, and high. Between-group comparisons used chi-squared testing. Adjusted logistic regression was used to analyze predictors of in-hospital mortality. Multivariate linear regression was performed after logarithmic transformation of the outcome to identify factors associated with mean hospitalization costs; inflation adjusted to 2014 US dollars. Coefficients were exponentiated to yield percentage change associated with each predictor. RESULTS: Among 26,417 adults with gastric cancer (mean age 65.7 ± 14 years, 36.3% female, 55.3% non-Hispanic White), 48.6% were low-medium burden, and 22.4% were hospitalized in high SNB hospitals. Overall in-hospital mortality was 7%, with no significant differences by hospital SNB. Compared to men with gastric cancer, women had significantly lower odds of in-hospital mortality (7.3% vs. 6.4%; OR 0.81, 95% CI 0.73-0.89, P &lt; 0.001), and patients who received surgery (vs. no surgery) were less likely to experience in-hospital deaths (3.4% vs. 7.7%; OR 0.49, 95% CI 0.41-0.58, P &lt; 0.001). Total estimated hospitalization costs were $2.5 billion. On regression, mean inpatient costs were significantly higher for hospitalizations at a low-medium SNB hospital (vs. no burden) (4.6% higher, 95% CI 0.6-8.7%, P = 0.02). Patients who underwent partial/total gastrectomy (vs. no surgery) incurred greater costs (183% higher, 95% CI 176-190%, P &lt; 0.001). CONCLUSION: There were no significant differences in rates of in-hospital mortality by SNB, however, low-medium SNB hospitals bore majority of the economic burden. Men with gastric cancer were more likely to die during hospitalization. While those who received partial/total gastrectomy incurred higher costs, in-hospital mortality was lower compared to those who did not receive surgery.

1068 Ethnic Minorities With Primary Biliary Cholangitis in the U.S. Are More Likely to Be Hospitalized at Higher Safety-Net Burden Hospitals

INTRODUCTION: Primary biliary cholangitis (PBC) is a progressive cholestatic liver disease associated with significant morbidity; its progression to cirrhosis and its complications contributes to significant healthcare resource utilization. Underserved communities, which include safety-net hospital populations, represent a major contributor to healthcare costs in the US. We aim to evaluate ethnic disparities by safety-net burden (SNB) and associated hospitalization costs. METHODS: Using the 2012-2014 National Inpatient Sample, we evaluated US adults hospitalized with PBC (using ICD-9 codes). Hospital SNB was defined as percentage of hospitalizations with PBC with Medicaid or uninsured payer status per hospital, and was categorized into two groups: no SNB vs. any SNB. Ethnicity-specific differences by SNB were analyzed with chi-squared testing. Logistic regression was used to analyze odds of being hospitalized at a SNB hospital (vs. no SNB). Multivariate linear regression was performed after logarithmic transformation of the outcome to identify factors associated with mean hospitalization costs, inflation-adjusted to 2014 US dollars. Coefficients were exponentiated to yield percentage change associated with each predictor. RESULTS: Among 7,364 hospitalizations with PBC (mean age 64.0 + 14.3 years, 16.1% men, 70.3% non-Hispanic white, 11.8% Hispanic, 5.9% African-American), 65.3% were no SNB and 34.7% with higher SNB. Compared to non-Hispanic whites, Hispanics (30.5% vs 52.1%; OR: 2.49, 95% CI: 2.02-3.05, P &lt; 0.001) and African-Americans (30.5% vs 43.3%; OR: 1.75, 95% CI: 1.38-2.21, P &lt; 0.001) were more likely to be hospitalized at a hospital with SNB. From 2012-2014, the total estimated national burden of PBC hospitalizations was $564 million. On adjusted regression, being admitted to a hospital with SNB (vs. no SNB) resulted in higher mean hospitalization costs (9.0% higher, 95% CI: 2.7%-15.6%, P &lt; 0.001). African-Americans had higher mean hospitalization costs compared to non-Hispanic whites (11.4% higher, 95% CI: 1.6%-22.3%, P = 0.02). Finally, larger (vs. small) and urban (vs. rural) hospitals were more likely to have higher hospitalization costs, and hospitals in the Western region (vs. Northeast) were also more likely to have higher hospitalization costs. CONCLUSION: Among hospitalized adults with PBC, ethnic minorities were significantly more likely to be cared for at SNB hospitals. African-Americans and Hispanics had a higher inpatient economic burden compared to non-Hispanic whites.

The Impact of Hospital Safety-Net Burden on Survival and Receipt of Chemoradiation in Anal Cancer Patients

To determine if hospital safety-net burden impacts overall survival and delivery of care in patients with anal squamous cell carcinoma (SCC). The National Cancer Database (NCDB) was queried for patients diagnosed with anal SCC from 2004-2013. Hospitals were categorized based on the percentage of uninsured/Medicaid-insured patients treated at each facility, with hospitals in the 0-29th percentiles defined as no safety-net burden hospitals (NBH), hospitals in the 30-75th percentiles defined as low safety-net burden hospitals (LBH), and hospitals at the 75th percentile or above defined as high safety-net burden hospitals (HBH). Patient, facility, tumor, and treatment characteristics were compared using chi-squared analysis. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were computed. Overall survival rates were estimated using the Kaplan-Meier method. Cox regression modeling was used to calculated crude and adjusted hazard ratios (aHR) with 95% CI. There were 298 HBH, 534 LBH, and 360 NBH identified with 4,669, 13,407, and 2,831 cases of anal cancer treated at each, respectively. The median percentage of uninsured/Medicaid patients treated was 31.3% (range 23.3-100%) at HBH, 11.5% (range 1.8-23.1%) at LBH, and 0% (range 0-0%) at NBH. Patients at HBH were more likely to be black or Hispanic, have incomes <$30,000, or have Stage III-IV disease (Table). Median follow-up in all patients was 39.3 months and 48.8 months in surviving patients. Five-year survival for anal cancer patients treated at HBH, LBH, and NBH was 65.5%, 71.2%, and 69.2%, respectively (p<0.0001). On univariate analysis, HBH was associated with worse survival vs. NBH (HR 1.16; 95% CI 1.04-1.29, p=0.009). On multivariate analysis adjusting for age, gender, race, Hispanic origin, insurance, income, education, comorbidities, stage, treatment modality, facility type, volume, and distance, there was no statistically significant difference in survival comparing HBH vs. NBH (aHR = 0.99; 95% CI 0.89-1.10, p=0.82). There was no difference in survival comparing LBH to NBH or HBH. For patients with Stage I-III anal cancer, odds of receiving chemoradiation did not vary by safety-net burden (HBH vs. NBH: aOR 1.04; 95% CI 0.93-1.17, p=0.46; LBH vs. NBH: aOR 0.98; 95% CI 0.89-1.08, p=0.62). High safety-net burden hospitals care for a higher proportion of anal cancer patients with underrepresented minority backgrounds, low income, and more advanced disease. Survival after anal cancer treatment and receipt of chemoradiation for Stage I-III disease were not significantly associated with hospital safety-net burden.Abstract 2366; Table 1Selected patient and tumor characteristics by hospital safety-net burden.NBHLBHHBHp-valueBlack race170 (6.0%)1340 (10.0%)770 (16.5%)<0.0001Hispanic109 (3.9%)564 (4.2%)391 (8.4%)<0.0001Income <$30,000241 (8.5%)1685 (12.6%)1049 (22.5%)<0.0001Stage III-IV868 (30.7%)4311 (32.2%)1684 (36.1%)<0.0001 Open table in a new tab

Social Determinants of Health and Clinicopathological Characteristics Impacting Survival in Laryngeal Cancer Patients: An Analysis By Hospital Safety-Net Burden

Social Determinants of Health and Clinicopathological Characteristics Impacting Survival in Laryngeal Cancer Patients: An Analysis By Hospital Safety-Net Burden

Survival and Receipt of Trimodality Therapy for Patients with Esophageal Cancer: An Analysis of Hospital Safety-Net Burden

To study the impact of hospital safety-net burden on survival and the receipt of trimodality therapy, with chemoradiation (CRT) followed by surgery, for patients with esophageal cancer. The National Cancer Database was queried for patients diagnosed with non-metastatic esophageal squamous cell carcinoma (SCC) or adenocarcinoma from 2004-2013. Hospitals were categorized based on the percentage of uninsured/Medicaid-insured patients treated at each facility, with hospitals in the 0-38thpercentile defined as no safety-net burden hospitals (NBH), hospitals in the 39-75thpercentiles defined as low safety-net burden hospitals (LBH), and hospitals at the 75thpercentile or above defined as high safety-net burden hospitals (HBH). Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were computed for receipt of surgery following CRT, vs. CRT alone. Cox regression modeling was used to calculate adjusted hazard ratios (aHR) for survival. There were 460 NBH, 420 LBH, and 281 HBH identified with 3,139, 11,094, and 3,631 patients, respectively. The median percentage of uninsured/Medicaid patients treated was 0% (range 0-0%) at NBH, 8.9% (range 1.5-16.7%) at LBH, and 25.0% (range 17.2-100%) at HBH. Only 9.8% of NBH were classified as academic/research programs, compared to 25.2% of LBH and 24.6% of HBH. Patients treated at HBH were more likely to be black, have incomes <$30,000, and have SCC histology with clinical Stage III-IVa disease (Table). Median follow-up in all and surviving patients was 19.2 and 40.6 months, respectively. Median survival was 21.5 months, and the overall 5-year survival was 24.8%. On both univariate analysis and multivariate analysis, adjusting for age, gender, race, Hispanic origin, income, comorbidities, insurance status, stage, histology, primary site, facility type and volume, treatment, and time to treatment, there was no significant survival difference after treatment at HBH (aHR 1.01; 95% CI 0.95-1.07, p=0.75) or LBH (aHR 1.02; 95% CI 0.97-1.08, p=0.38) compared to NBH. Odds of receiving surgery following CRT did not vary by safety-net burden (HBH vs. NBH: aOR 0.94; 95% CI 0.83-1.06, p=0.31; LBH vs. NBH: aOR 0.95; 95% CI 0.86-1.06, p=0.36). Safety-net burden did not impact survival or receipt of trimodality therapy on subgroup analyses stratified by histology or stage. High safety-net burden hospitals were more likely to treat esophageal patients with lower socioeconomic status and adverse clinicopathologic risk factors, without adversely impacting survival or the receipt of trimodality therapy, irrespective of tumor histology and stage.Abstract 2439; Table 1Selected patient and tumor characteristics by hospital safety-net burdenNBHLBHHBHp-valueBlack race171 (5.5%)948 (8.6%)717 (19.8%)<0.0001Income <$30,000284 (9.1%)1,385 (12.5%)851 (23.4%)<0.0001SCC1,055 (33.6%)3,540 (31.9%)1,617 (44.5%)<0.0001Stage III-IVa1,415 (45.1%)5,034 (45.4%)1,795 (49.4%)<0.0001 Open table in a new tab

The Impact of Hospital Safety-Net Burden on Outcomes for Primary Supratentorial Brain Tumor Surgery

Abstract INTRODUCTION Safety-net hospitals treat a disproportionate share of vulnerable patient populations. While outcomes at these institutions for neurosurgical procedures, such as cerebral aneurysm surgery, have been researched, the impact of safety-net burden on brain tumor surgery is poorly characterized. METHODS Using International Classification of Diseases-9 diagnosis codes, we identified all adult admissions in the National Inpatient Sample from 2002 to 2011 undergoing craniotomy for a primary supratentorial brain tumor (191.0-5, 191.8-9, 225.0 and 237.5), excluding patients with brain metastasis (198.3). For each hospital, we quantified safety-net burden as the percentage of patients on Medicaid or without insurance. Hospitals in the top quartile of safety-net burden were categorized as high-burden hospitals (HBHs) while the remainder were low-burden hospitals (LBHs). Survey-weighted multivariate regression was used to make national estimates and adjust for 12 confounding variables: age, sex, insurance, household income, severity of illness and risk of mortality scores, Charlson Comorbidity Index, malignant status, hospital ownership, teaching status, region, and volume. RESULTS We analyzed 162 828 total admissions admitted to 1135 hospitals for brain tumor craniotomy in 2002 to 2011. A total of 212 hospitals (19%) were classified as HBHs, treating 16 914 admissions. HBHs were more likely to be low-volume and public hospitals (both P &lt; .001). Moreover, patients at HBHs were less likely to be white and had higher severity of illness scores (both P &lt; .001). When evaluating outcomes, hospital safety-net status was not associated with mortality (P = .260), favorable discharge disposition (P = .765), or perioperative complications (P = .757). However, admission to HBHs was associated with higher length of stay (+ 0.74 d, P = .007) and inpatient costs (+ $2 448, P = .002). CONCLUSION Although safety-net burden was not associated with mortality, disposition, or complications, patients at safety-net hospitals exhibited increased length of stay and costs, potentially due to factors like resource limitations or more advanced disease presentation among safety-net patients. Amidst potential reforms like “pay-for-performance” reimbursement models, it is critical to further study neurosurgical outcomes at safety-net hospitals.

The effect of hospital safety-net burden on outcomes, cost, and reportable quality metrics after emergent clipping and coiling of ruptured cerebral aneurysms.

Safety-net hospitals deliver care to a substantial share of vulnerable patient populations and are disproportionately impacted by hospital payment reform policies. Complex elective procedures performed at safety-net facilities are associated with worse outcomes and higher costs. The effects of hospital safety-net burden on highly specialized, emergent, and resource-intensive conditions are poorly understood. The authors examined the effects of hospital safety-net burden on outcomes and costs after emergent neurosurgical intervention for ruptured cerebral aneurysms. The authors conducted a retrospective analysis of the Nationwide Inpatient Sample (NIS) from 2002 to 2011. Patients ≥ 18 years old who underwent emergent surgical clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage (SAH) were included. Safety-net burden was defined as the proportion of Medicaid and uninsured patients treated at each hospital included in the NIS database. Hospitals that performed clipping and coiling were stratified as low-burden (LBH), medium-burden (MBH), and high-burden (HBH) hospitals. A total of 34,647 patients with ruptured cerebral aneurysms underwent clipping and 23,687 underwent coiling. Compared to LBHs, HBHs were more likely to treat black, Hispanic, Medicaid, and uninsured patients (p < 0.001). HBHs were also more likely to be associated with teaching hospitals (p < 0.001). No significant differences were observed among the burden groups in the severity of subarachnoid hemorrhage. After adjusting for patient demographics and hospital characteristics, treatment at an HBH did not predict in-hospital mortality, poor outcome, length of stay, costs, or likelihood of a hospital-acquired condition. Despite their financial burden, safety-net hospitals provide equitable care after surgical clipping and endovascular coiling for ruptured cerebral aneurysms and do not incur higher hospital costs. Safety-net hospitals may have the capacity to provide equitable surgical care for highly specialized emergent neurosurgical conditions.

Esophageal Cancer Presentation, Treatment, and Outcomes Vary With Hospital Safety-Net Burden

Social determinants of health affect diagnosis and delivery of care to patients with esophageal cancer. This study hypothesized that hospital safety-net burden affects presentation, treatment, and outcomes in patients with esophageal cancer. The National Cancer Database was queried for patients with esophageal cancer (2004 to 2013). Treating facilities were categorized according to their relative burden of uninsured or Medicaid-insured patients. Hospitals with low (LBH), medium (MBH), and high (HBH) safety-net burden were compared with respect to patient demographics, disease and treatment characteristics, and survival using χ2 analysis, Kaplan-Meier survival analysis, and multivariable modeling. There were 56,115 patients from 1,215 facilities. HBH treated a greater proportion of racial and ethnic minorities and patients with lower socioeconomic status. Patients at HBH presented at later stages and received primary surgical therapy less often than at MBH and LBH. Survival for patients with esophageal adenocarcinoma did not differ significantly between HBH and LBH after adjusting for age, sex, race, ethnicity, income, comorbidity, stage, histologic type, tumor location, facility type, insurance status, and treatment modality (hazard ratio, 1.06; 95% confidence interval, 0.99 to 1.14; p= 0.093). HBH were associated with a higher mortality risk than LBH for patients with squamous cell carcinoma (hazard ratio, 1.11; 95% confidence interval, 1.02 to 1.20; p= 0.014). There is a mortality risk for patients with squamous cell carcinoma, but not for adenocarcinoma at HBH compared with LBH. Further analysis of unadjusted variables such as performance status, completion of therapy, and continuity of care, and others should be undertaken among safety-net hospitals with the goal of creating appropriate clinical pathways for care of esophageal cancer in vulnerable populations.

Cardiorespiratory morbidity and mortality of opioid overdose during admission to safety-net hospitals

Study objectiveSafety-net hospitals disproportionately care for high-risk patients. Prior work has shown safety-net hospitals to have inferior postoperative outcomes with higher cost and worse patient ratings. We aim to examine the association of hospital safety-net burden with morbidity and mortality in patients with opioid overdose hospital admission. DesignRetrospective cross-sectional analysis using the National Inpatient Sample registry from 2010 to 2014. SettingMulti-institutional. PatientsWe included 547, 399 patients admitted to a United States hospital with an International Classification of Disease, Ninth Revision, code of opioid overdose. To study the association of hospital safety-net burden on mortality and morbidity, we calculated hospital safety-net burden defined as the percent of Medicaid or uninsured among all admitted patients. Hospitals were categorized into one of three categories: low burden hospitals, medium burden hospitals, and high burden hospitals (i.e., safety-net hospitals). We performed a mixed effects multivariable logistic regression analysis to assess the association of hospital safety-net burden with short-term inpatient outcomes. InterventionNone. MeasurementsThe primary outcomes were inpatient mortality and morbidity. Main resultsCompared to MBHs and LBHs, HBHs had a greater proportion of minority patients (i.e., Black, Hispanic, and Native American) and patients with median household income in the lowest quartile (p < 0.001). Among prescription opioid overdose admissions, the odds of inpatient mortality and pulmonary and cardiac morbidity were also not significantly higher between HBHs versus LBHs (p > 0.05). ConclusionsSafety-net hospital disproportionately care for vulnerable populations, however the odds of poor outcomes were no different in opioid overdose. Safety-net hospitals should have equal access to the funding and resources that allows them to deliver the same standard of care as their counterparts.

Safety-Net Hospitals Have Higher Complication and Mortality Rates in the Neurosurgical Management of Traumatic Brain Injuries

Clinical outcomes in the surgical management of severe traumatic brain injury (TBI) have been shown to vary across different hospital institutions. The effect of the safety-net burden on postoperative mortality, complication rates, and failure to rescue rates is unclear. We evaluated the relationship of the safety-net burden with outcomes in the treatment of patients with severe TBI undergoing neurosurgery. The hospitals were grouped according to their safety-net burden, defined as the proportion of Medicaid and uninsured patient charges for all hospitalizations during that time. Multivariate analyses were performed to examine significant associations with the degree of safety-net burden while controlling for potential confounders. Data from 20,989 encounters in 788 hospitals were included. Compared with low-burden hospitals (LBHs), high-burden hospitals (HBHs; odds ratio [OR], 1.48; 95% confidence interval [CI], 1.04-2.12; P= 0.03) had greater mortality rates. Major complications were more likely to occur at HBHs (OR, 1.44; 95% CI, 1.12-1.84; P < 0.01) compared with LBHs. The failure to rescue rates were similar among all safety-net burden hospital groups. Patients at HBHs also had an increased likelihood of an extended length of stay (OR, 1.92; 95% CI, 1.12-3.29; P= 0.02) and receiving a tracheostomy or gastrostomy (OR, 1.99; 95% CI, 1.36-2.89; P < 0.01) compared with patients at LBHs. The present study found that a greater hospital safety-net burden was independently associated with greater rates of mortality and major complications in the treatment of patients with severe TBI undergoing neurosurgery. Further research in evaluating the cause of disparities in mortality outcomes at high safety-burden hospitals is needed.

Impact of hospital safety-net burden on oncology patterns of care and outcomes.

6567Background: Safety-net hospitals serve a vital role in treating underserved populations. These hospitals often receive less funding, which could lead to different patterns of care for patients ...

Hospital safety-net burden does not predict differences in rectal cancer treatment and outcomes

BackgroundSafety-net hospitals have been shown to have inferior short-term surgical outcomes. The aim of this study was to compare rectal cancer management and survival across hospitals stratified by payer mix. Materials and methodsRectal cancer patients (n = 296,068) were identified using the 1998-2010 National Cancer Data Base. Hospitals were grouped into safety-net burden categories, according to the proportion of patients with Medicaid or no health insurance, as follows: low-, medium-, and high-burden hospitals (HBHs). Patient and tumor characteristics, processes of care, and outcomes were evaluated, and regression analysis was used to investigate correlations between hospital safety-net burden on patient survival. ResultsHBH encountered patients with more advanced disease (P < 0.001). Despite this, stage I-III patients at HBH had equal likelihood of receiving surgery and guideline-appropriate radiation and chemotherapy (all P > 0.05). The 30-day readmissions and mortality were also similar across safety-net groups (all P > 0.05). Multivariate analysis showed no difference in survival between HBH and low-burden hospital (P = 0.164). ConclusionsHospital payer mix may not adversely influence management of rectal cancer. This study highlights potential areas to improve cancer care for vulnerable patient populations.

Addressing the quality and cost of cholecystectomy at a safety net hospital

BackgroundThe aim of this study was to evaluate the effects of safety-net burden on outcomes of a common, urgent operation like cholecystectomy. MethodsWe identified all cholecystectomies performed from 2005 to 2011 in the California State Inpatient Database and separated them into three cohorts based on the performing hospital's safety-net burden. Hierarchical multivariable regression analyses were performed with outcomes including laparoscopy, advanced disease, morbidity, length of hospitalization, and cost. ResultsSafety-net hospitals had similar rates of laparoscopy, overall advanced disease, and post-operative morbidity. Yet, they were able to maintain lower overall costs (cost difference −5592, 95% CI -8928, −2256, p < 0.01), despite having similar lengths of stay. ConclusionSafety-net hospitals performed cholecystectomy with similar rates of laparoscopy and morbidity, while achieving lower costs. Safety-net hospitals may be well equipped to perform common, urgent operations like cholecystectomy.

Effects of hospital safety-net burden and hospital volume on failure to rescue after open abdominal aortic surgery

ObjectiveFailure to rescue (FTR) is defined as the inability to rescue a patient from major perioperative complications, resulting in operative mortality. FTR is a known contributor to operative mortality after open abdominal aortic surgery. Understanding the causes of FTR is essential to designing interventions to improve perioperative outcomes. The objective of this study was to determine the relative contributions of hospital volume and safety-net burden (the proportion of uninsured and Medicaid-insured patients) to FTR. MethodsThe Nationwide Inpatient Sample (2001-2011) was analyzed to investigate variables associated with FTR after elective open abdominal aortic operations in the United States. FTR was defined as in-hospital death following postoperative complications. Mixed multivariate regression models were used to assess independent predictors of FTR, taking into account the clustered structure of the data (patients nested into hospitals). ResultsA total of 47,233 elective open abdominal aortic operations were performed in 1777 hospitals during the study period. The overall incidences of postoperative complications, in-hospital mortality, and FTR in the whole cohort were 32.7%, 3.2%, and 8.6%, respectively. After adjusting for demographics, comorbidities, and hospital characteristics, safety-net burden was significantly associated with increased likelihood of FTR (highest vs lowest quartile of safety-net burden, odds ratio, 1.59; 95% confidence interval, 1.32-1.91; P < .0001). In contrast, after adjusting for safety-net burden, procedure-specific hospital volume was not significantly associated with FTR (P = .897). ConclusionsAfter adjusting for patient- and hospital-level variables, including hospital volume, safety-net burden was an independent predictor of FTR after open aortic surgery. Future investigations should be aimed at better understanding the relationship between safety-net hospital burden and FTR to design interventions to improve outcomes after open abdominal aortic surgery.

Error in Abstract and Table in: The Effect of Hospital Safety-Net Burden Status on Short-term Outcomes and Cost of Care After Head and Neck Cancer Surgery

Error in Abstract and Table in: The Effect of Hospital Safety-Net Burden Status on Short-term Outcomes and Cost of Care After Head and Neck Cancer Surgery

The Effect of Hospital Safety-Net Burden Status on Short-term Outcomes and Cost of Care After Head and Neck Cancer Surgery

To determine the association between safety-net hospital care and short-term outcomes after head and neck cancer surgery. Cross-sectional analysis. Safety-net burden was calculated as the percentage of patients with head and neck cancer with Medicaid or no insurance. Nationwide Inpatient Sample database. Adults who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm in 2001 through 2008. Associations between hospital safety-net burden and short-term morality, medical and surgical complications, length of hospitalization, and costs. Overall, 123 662 patients underwent surgery in 2001 through 2008. Patients treated at high-safety-net burden hospitals were significantly more likely to be admitted urgently or emergently (odds ratio [OR], 1.54; 95% CI, 1.06-1.15 [P = .03]), undergo major surgical procedures (OR, 1.24; 95% CI, 1.09-1.39 [P = .001]), have advanced comorbidity (OR, 1.35; 95% CI, 1.06-1.72 [P = .02]), and be black (OR, 1.70; 95% CI, 1.29-2.23 [P < .001]), but less likely to be elderly (OR, 0.66; 95% CI, 0.53-0.82 [P < .001]). High safety-net burden hospitals were significantly more likely to be teaching hospitals (OR, 2.04; 95% CI, 1.26-3.29 [P = .004]) and less likely to be located in the West (OR, 0.18; 95% CI, 0.07-0.44 [P < .001]). Safety-net burden was not associated with in-hospital mortality, acute medical complications, surgical complications, or hospital-related costs after controlling for all other variables including hospital volume status, but was associated with a mean increase in length of hospitalization of 24 hours (P < .001). These data suggest that safety-net hospitals provide valuable specialty care to a vulnerable population without an increase in complications or costs. Health care reform must address the economic challenges that threaten the viability of these institutions at the same time that demand for their services increases.

Safety-Net Burden Hospitals and Likelihood of Curative-Intent Surgery for Non-Small Cell Lung Cancer

Black patients are less likely to undergo surgery for early-stage non-small cell lung cancer (NSCLC) compared with white patients, and are more likely to undergo resection at low-volume hospitals. However, little is known about the relationship between hospital safety-net burden and the likelihood of curative-intent surgery for black and white patients. This study analyzes whether hospital safety-net burden is associated with curative-intent surgery among adult early-stage NSCLC patients treated at facilities accredited by the American College of Surgeons Commission on Cancer. Adult patients diagnosed with invasive initial primary early-stage (TNM I-II) NSCLC during 2003-2005 were obtained from the National Cancer Data Base. Curative-intent surgery included anatomic resection, wedge resection, and segmentectomy. Hospital safety-net burden was defined as the percent of cancer patients per facility that were Medicaid-insured or uninsured. Generalized estimating equations and linear mixed models were used to control for clustering by facility. Of 52,853 evaluable patients, those treated at high safety-net burden facilities were significantly less likely (unadjusted p < 0.0001) to undergo curative-intent surgery than patients treated at low safety-net burden facilities. Controlling for patient and other facility characteristics, high safety-net burden remained significantly associated (p < 0.0001) with reduced likelihood of curative-intent surgery overall (odds ratio = 0.69; 95% CI, 0.62-0.77) and in black- and white-only models (odds ratio = 0.59, 95% CI, 0.48-0.73; odds ratio = 0.71; 95% CI, 0.63-0.80, respectively). Both black and white adult patients treated for early-stage NSCLC at high safety-net burden facilities are less likely to undergo curative-intent surgery than those treated at low safety-net burden facilities. Innovative solutions are needed to ensure quality cancer care at high safety-net burden facilities.