Medicare Hospital Research Articles

Role of Transamin in Reduction of Seroma in Post-Operative Mastectomy

Objective:The purpose of this study to determine the effectiveness of transamin in reduction of seroma in post-operative mastectomy. Study Design:Retrospective study Place and Duration: District Headquarter Hospital Attock and Medicare Hospital, Attock. September 2021-July 2022. Methods: There were 40 females had breast cancer with age 20-65 years were included. Patients were underwent for mastectomy and admitted to hospital. After obtaining informed written consent detailed demographics of enrolled cases included age, body mass index and socio-economic status was recorded. After surgery patients received injection of tranexamic acid. Outcomes among all patients were assessed in terms of reduction in seroma formation, wound infection, amount of drainage and time of drainage. SPSS 22.0 was used to analyze all data. Results: We found that 7 (20%) patients had age 21-30 years, 12 (30%) cases had age 31-40 years, 17 (42.5%) cases had age 41-50 years and 4 (10%) cases had age 51-65 years. 26 (65%) patients had BMI >25kg/m2 and 14 (35%) had BMI <25kg/m2. There were 22 (55%) patients had poor socio-economic status. Mean amount of drainage was 812.7±99.24 ml and mean time of drainage was 7.5±12.40 days. Frequency of seroma formation was found in 5 (12.5%) cases in which mostly had BMI >25kg/m2 and had increased age. Wound infection found in 3 (7.5%) cases. Conclusion:We concluded in this study use of tranexamic acid among patients undergoing mastectomy was affective and useful in terms of reduction in seroma formation and lower number of wound infection. Except this duration and volume of drainage was also seen lower in our study. Keywords: Breast Cancer, Mastectomy, Seroma, Tranexamic Acid, Complications

Implementing pharmacists' medication safety recommendations is associated with reduced health care resource utilization and mortality in high-risk older Americans

BackgroundA medication safety review (MSR) is a novel, pharmacist-driven, technology-supported intervention that prioritizes adverse drug event risk mitigation. Previous research has shown that Medicare Part D beneficiaries who received MSRs in an enhanced medication therapy management (EMTM) model realized improvements in total Medicare spending, hospitalizations, emergency department (ED) visits, and mortality compared to control. However, it is unknown whether beneficiaries implemented pharmacists’ MSR recommendations. ObjectiveThe objective of the study was to evaluate whether MSR recommendation implementation is associated with improvements in these same outcomes for Part D beneficiaries enrolled in EMTM compared to a control group. MethodsThis retrospective, pre-post, cohort study evaluated outcomes for beneficiaries who were targeted for MSR services in 2018 and 2019. The “validated implementation MSR (viMSR)” cohort included those who received their first-ever MSR in 2018, received another MSR in 2019, and validated implementation of ≥1 recommendation in their 2018 MSR. The “failed to engage” (FTE) cohort included beneficiaries who were targeted for MSR services in both 2018 and 2019 but did not engage in an MSR at any point through the end of 2019. For both cohorts, we calculated the 2018-to-2019 change for each outcome and then determined whether year-over-year changes differed significantly between cohorts. For mortality, we relaxed the requirement for continuous enrollment in 2019, permitting us to compare the proportion of beneficiaries that died in each group in 2019. Analyses were adjusted for baseline multimorbidity. ResultsOf 4384 beneficiaries who completed MSRs, 602 (13.7%) implemented ≥1 recommendation. The viMSR cohort (N = 602) outperformed the FTE cohort (N = 7052) in total Medicare costs ($2162/y lower; P = 0.020), Part A Medicare costs ($1855/y; P = 0.024), hospitalizations (9.1 fewer admissions/100 beneficiaries/y, P = 0.020), ED visits (10.8 fewer visits/100 beneficiaries/y, P = 0.014), and mortality (3.8% fewer died in 2019; P < 0.001). ConclusionImplementing pharmacists’ recommendations in MSRs was associated with improved health care resource utilization and mortality for MSR-eligible beneficiaries.

Age-Stratified 30-day Rehospitalization and Mortality and Predictors of Rehospitalization Among Patients With Systemic Lupus Erythematosus: A Medicare Cohort Study.

Recent studies suggest young adults with systemic lupus erythematosus (SLE) have high 30-day readmission rates, which may necessitate tailored readmission reduction strategies. To aid in risk stratification for future strategies, we measured 30-day rehospitalization and mortality rates among Medicare beneficiaries with SLE and determined rehospitalization predictors by age. In a 2014 20% national Medicare sample of hospitalizations, rehospitalization risk and mortality within 30 days of discharge were calculated for young (aged 18-35 yrs), middle-aged (aged 36-64 yrs), and older (aged 65+ yrs) beneficiaries with and without SLE. Multivariable generalized estimating equation models were used to predict rehospitalization rates among patients with SLE by age group using patient, hospital, and geographic factors. Among 1.39 million Medicare hospitalizations, 10,868 involved beneficiaries with SLE. Hospitalized young adult beneficiaries with SLE were more racially diverse, were living in more disadvantaged areas, and had more comorbidities than older beneficiaries with SLE and those without SLE. Thirty-day rehospitalization was 36% among young adult beneficiaries with SLE-40% higher than peers without SLE and 85% higher than older beneficiaries with SLE. Longer length of stay and higher comorbidity risk score increased odds of rehospitalization in all age groups, whereas specific comorbid condition predictors and their effect varied. Our models, which incorporated neighborhood-level socioeconomic disadvantage, had moderate-to-good predictive value (C statistics 0.67-0.77), outperforming administrative data models lacking comprehensive social determinants in other conditions. Young adults with SLE on Medicare had very high 30-day rehospitalization at 36%. Considering socioeconomic disadvantage and comorbidities provided good prediction of rehospitalization risk, particularly in young adults. Young beneficiaries with SLE with comorbidities should be a focus of programs aimed at reducing rehospitalizations.

The National Strategies for and Challenges in Infection Prevention and Control of the Healthcare System in the Kingdom of Saudi Arabia (Review Study).

Healthcare-associated infections (HAIs) lead to considerable morbidity. Prolonged hospital HAIs, also known as hospital infections or nosocomial infections, refer to infectious diseases that occur within 48 h of hospital admission, within three days of discharge or 30 days after having received healthcare. A total of 39 government-owned hospitals with a total of 10,822 beds providing the majority (59.9%) of Saudi Arabian healthcare were analyzed. Medicare and Medicaid use hospital data to track hospital performance on matters pertaining to IPC. In addition, many hospitals have limited capacity with which to develop the core components required to build an effective IPC programme. Hajj has been associated with the increased prevalence and spread of infectious diseases. These factors include changes in human demographics and behaviour, the effect of new technologies and industries, an increase in international travel and commerce, and breakdown resulting from public health measures. Overall public health service expenditure originates from the administration and services that are provided free of charge to all Saudi citizens.

Family Medicine Residencies: How Rural Training Exposure in GME Is Associated With Subsequent Rural Practice.

Rural US populations face a chronic shortage of physicians and an increasing gap in life expectancy compared to urban US populations, creating a need to understand how to increase residency graduates' desire to practice in such areas. This study quantifies associations between the amount of rural training during family medicine (FM) residencies and subsequent rural work. American Medical Association (AMA) Masterfile, AMA graduate medical education (GME) supplement, American Board of Family Medicine certification, Accreditation Council for Graduate Medical Education (ACGME), and Centers for Medicare and Medicaid Services hospital costs data were merged and analyzed. Multiple logistic regression measured associations between rural training and rural or urban practice in 2018 by all 12 162 clinically active physicians who completed a US FM residency accredited by the ACGME between 2008 and 2012. Analyses adjusted for key potential confounders (age, sex, program size, region, and medical school location and type) and clustering by resident program. Most (91%, 11 011 of 12 162) residents had no rural training. A minority (14%, 1721 of 12 162) practiced in a rural location in 2018. Residents with no rural training comprised 80% (1373 of 1721) of those in rural practice in 2018. Spending more than half of residency training months in rural areas was associated with substantially increased odds of rural practice (OR 5.3-6.3). Only 4% (424 of 12 162) of residents spent more than half their training in rural locations, and only 5% (26 of 436) of FM training programs had residents training mostly in rural settings or community-based clinics. There is a linear gradient between increasing levels of rural exposure in FM GME and subsequent rural work.

Internal Operational Metrics and Center for Medicare and Medicaid Services Hospital Compare Quality Ratings.

The Center for Medicare and Medicaid Services (CMS) has made several refinements to their model for calculating hospital quality star ratings (Hospital Compare) amidst criticism and evidence of bias against some institutions. We argue that the CMS model does align with important internal quality metrics and encourage a measured approach to redesign, potentially using categorizations or tiers, rather than a complete abandonment of the ratings system. We find that institutional characteristics (available resources, average severity of illness, and academic affiliation) are associated with internal quality metrics related to patient flow. Furthermore, regression results from the original and revised CMS star rating methodologies suggest that patient flow metrics (discharges before noon [p < .01] and weekend discharges [p < .001]) have a positive relationship with the Hospital Compare rating. Hospitals with better patient flow, as measured by higher levels of discharges before noon and weekend discharges, are associated with higher CMS quality ratings. These findings suggest that CMS star ratings do reflect key aspects of operational performance, specifically efforts to improve patient flow, but the ranking system should consider hospital characteristics that influence internal operations as we move toward a system capable of quality and price transparency for consumers.

The Hospital Value-Based Purchasing Program: Do hospitalists improve health care value.

As healthcare organizations examine the associated benefits of employing a larger hospitalist workforce, there is a need to better understand the association with patients' quality, experience, and efficiency. However, there is a lack of information regarding how hospital use of hospitalists over time influences hospital scoring on quality programs, such as the Center for Medicare and Medicaid Services (CMS) Hospital Inpatient Value-Based Purchasing (HVBP) Program. This study examines the association between hospitalist staffing between 2014 and 2019 and HVBP scores. We used a cross-sectional panel study design. Total Performance Score (TPS) and its domains were obtained from CMS from 2014 to 2019 and merged with the American Hospital AssociationAnnual Survey Database. We utilized random-effects multivariable panel regression models and zero-inflated negative binomial regression to examine the association between the hospitalist-staffing ratio and the HVBP Program. All models were adjusted for hospital characteristics. A total of 2126 hospitals were included in the study. The average ratio of hospitalists per staffed bed was 0.06, with a standard deviation of 0.15. This study suggests that hospitals that employ a higher percentage of hospitalists see improvement in their overall TPS (β = 5.40; p < .001), Patient Experience (β = 2.49; p <.05), andEfficiency (incidence-rate ratio= 1.41; p < .001) domain. However, the Clinical Care domain was no different in organizations employing more hospitalists. There are benefits associated with TPS, Patient Experience, and Efficiency from employing hospitalists. Managers should seek opportunities to leverage hospitalists' expertise in providing care, particularly in improving care processes.

The Influence of Regulatory Change on Hospital Medicare Cost Reporting

ABSTRACT Hospitals function within an environment in which regulation influences their daily operation, reporting, and reimbursement. This study tests whether regulatory reporting is affected by significant regulatory change. To examine whether this relationship exists, we utilize a comprehensive sample of more than 22,000 Medicare cost reports (MCRs) and corresponding MCR status changes spanning 2007–2014, surrounding the passage of the Patient Protection and Affordable Care Act of 2010 (“ACA”). We find that hospitals restate more Medicare cost reports in the post-ACA (2012–2014) period suggesting that regulatory reporting accuracy declines overall. The analysis is expanded to examine reporting accuracy across hospital types. There is an increase in MCR restatements by all hospitals following the ACA, but the timing varies. Further analysis reveals that the increase in restatements following the ACA is due to an increase in amended returns that outweighs a decline in MCRs that are reopened following their settlement.

A Learning Health System Approach to Hospital Quality Performance Benchmarking: The Composite Hospital Quality Index.

US hospital quality rankings and ratings use disparate methodologies and are weakly correlated. This causes confusion for patients and hospital quality staff. At the authors' institution, a Composite Hospital Quality Index (CHQI) was developed to combine hospital quality ratings. This approach is described and a calculator is shared here for other health systems to explore their performance. Among the US News and World Report Top 50 Hospitals, hospital-specific numeric summary scores were aggregated from the 2021 Centers for Medicare and Medicaid Services (CMS) Hospital Overall Star Rating, the Spring 2021 Leapfrog Safety Grade, and the April 2021 Hospital Consumer Assessment of Healthcare Providers and Systems Star Rating. The CHQI is the hospital-specific sum of the national percentile-rankings across these 3 ratings. In this example, mean (SD) percentiles were as follows: CMS Stars 74 (19), Hospital Consumer Assessment of Healthcare Providers and Systems 63 (19), Leapfrog 65 (24), with mean (SD) CHQI of 202 (49). The CHQI is used at the authors' institution to identify improvement opportunities and ensure that high-quality care is delivered across the health system.

Impactability Modeling for Reducing Medicare Accountable Care Organization Payments and Hospital Events in High-Need High-Cost Patients: Longitudinal Cohort Study.

BackgroundImpactability modeling promises to help solve the nationwide crisis in caring for high-need high-cost patients by matching specific case management programs with patients using a “benefit” or “impactability” score, but there are limitations in tailoring each model to a specific program and population.ObjectiveWe evaluated the impact on Medicare accountable care organization savings from developing a benefit score for patients enrolled in a historic case management program, prospectively implementing the score, and evaluating the results in a new case management program.MethodsWe conducted a longitudinal cohort study of 76,140 patients in a Medicare accountable care organization with multiple before-and-after measures of the outcome, using linked electronic health records and Medicare claims data from 2012 to 2019. There were 489 patients in the historic case management program, with 1550 matched comparison patients, and 830 patients in the new program, with 2368 matched comparison patients. The historic program targeted high-risk patients and assigned a centrally located registered nurse and social worker to each patient. The new program targeted high- and moderate-risk patients and assigned a nurse physically located in a primary care clinic. Our primary outcomes were any unplanned hospital events (admissions, observation stays, and emergency department visits), count of event-days, and Medicare payments.ResultsIn the historic program, as expected, high-benefit patients enrolled in case management had fewer events, fewer event-days, and an average US $1.15 million reduction in Medicare payments per 100 patients over the subsequent year when compared with the findings in matched comparison patients. For the new program, high-benefit high-risk patients enrolled in case management had fewer events, while high-benefit moderate-risk patients enrolled in case management did not differ from matched comparison patients.ConclusionsAlthough there was evidence that a benefit score could be extended to a new case management program for similar (ie, high-risk) patients, there was no evidence that it could be extended to a moderate-risk population. Extending a score to a new program and population should include evaluation of program outcomes within key subgroups. With increased attention on value-based care, policy makers and measure developers should consider ways to incorporate impactability modeling into program design and evaluation.

Hospital Prices for Pediatric Tympanostomy Tube Placement and Adenotonsillectomy in 2021.

Hospital prices vary substantially for myringotomy with tympanostomy tube placement (M&T) and adenotonsillectomy (T&A). The Centers for Medicare and Medicaid Services recently implemented hospital price transparency requirements to help families make financially informed decisions about where to seek care. We sought to determine price availability and the extent of price variation for these procedures. We performed a cross-sectional analysis of the Turquoise Health Hospital Rates Data Platform, which extracts prices for facility fees from publicly available hospital chargemasters. We determined the proportion of hospitals serving pediatric patients that published payer-specific prices for M&T and T&A. We additionally characterized the extent of variation in payer-specific prices both across and within hospitals. Approximately 40% (n=909 of 2,266 hospitals) serving pediatric patients disclosed prices for M&T or T&A. Among disclosing hospitals, across-center ratios (adjusted for Medicare hospital wage indices) ranged from 11.0 (M&T; 10th percentile adjusted median price: $536.80 versus 90th percentile adjusted median price: $5,929.93) to 23.4 (revision adenoidectomy age >12 years; 10th percentile: $393.82 versus 90th percentile: $9,209.88). Median within-center price ratios for procedures ranged from 2.2 to 2.7, indicating that some private payers reimbursed the same hospital more than twice as much as other payers for the same procedure. The majority of hospitals serving pediatric patients were non-compliant with federal requirements to disclose prices for M&T and T&A. Among disclosing hospitals, there was wide variation in payer-specific prices between and within institutions. Further research is necessary to understand whether disclosure of prices will enable families to make more financially informed decisions. 3 Laryngoscope, 133:948-955, 2023.

Medicare's Specialty-Oriented Accountable Care Organization: First-Year Results For People With End-Stage Renal Disease.

The Comprehensive End-Stage Renal Disease (ESRD) Care (CEC) Model was the first Medicare specialty-oriented accountable care organization (ACO) model. We examined whether this model provided better results for beneficiaries with ESRD than primary care-based ACO models. We found significant decreases in Medicare payments ($126 per beneficiary per month), hospitalizations (5percent), and likelihood of readmissions (8percent) among beneficiaries with ESRD during the first year of alignment with the CEC Model and no impacts on these measures among beneficiaries with ESRD who were aligned with primary care-based ACOs, relative to fee-for-service Medicare beneficiaries. Neither the CEC nor primary care-based ACO models significantly reduced the likelihood of catheter use, but fistula use increased for CEC Model beneficiaries to levels just above statistical significance. Other populations with chronic conditions may benefit from the testing of a specialty-oriented ACO model. In addition, primary care-based ACOs may benefit from applying CEC Model strategies to high-need subpopulations. Last, the strategies that enabled ESRD Seamless Care Organizations to achieve reductions in hospitalizations and readmissions even without hospital participation as owners could inform physician-led ACOs' efforts to coordinate with hospitals in their areas.

126-OR: Long-Term Consequences of Diabetic Foot Infection: The Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Foot infections are a common complication of type 2 diabetes. However, the clinical sequelae of diabetic foot infection (DFI) in the general population remain poorly characterized. Methods: We conducted a prospective cohort analysis of 1,451 participants with diabetes (mean age, 63 years [SD: 5.6]; 33% black; 47% female) in the ARIC study (visit 4: 1996-1998) . DFI was ascertained using ICD-9/codes from Medicare claims and hospital discharge records. We used Kaplan-Meier analyses to estimate the 5-year cumulative incidence of nontraumatic lower-extremity amputation (NLEA) , major fall, cardiovascular disease (CVD) [coronary heart disease, stroke, or heart failure], and death following incident DFI. We evaluated the association between incident DFI (modeled as a time-varying exposure) and the subsequent risk of clinical outcomes with Cox models. Results: During over two decades of follow-up (1996-1998 to 2017) , there were 328 incident DFIs, 72 NLEAs, 502 major falls, 748 CVD events, and 915 deaths. Following incident DFI, the five-year cumulative incidence of major clinical outcomes ranged from 14.7% (NLEA) to 38.6% (death) (Fig 1a) . Incident DFI was significantly associated with all clinical outcomes after multivariable adjustment (Fig 1b) . Conclusion: DFI is a high-risk marker for major morbidity and mortality in the general population of adults with diabetes. Disclosure M.Fang: n/a. J.Hu: None. K.Matsushita: Consultant; Akebia Therapeutics, Inc., Mitsubishi Tanabe Pharma Corporation, Other Relationship; Fukuda Denshi, Research Support; Kyowa Kirin Co., Ltd. E.Selvin: Other Relationship; Wolters Kluwer. C.W.Hicks: None. Funding HHS (N268201700001I) , HHS (N268201700002I) , HHS (N268201700003I) , HHS (N268201700005I) , HHS (N268201700004I) , NHLBI (K24HL152440)

Disparities in coronary artery bypass grafting between high- and low-volume surgeons and hospitals

BackgroundHigh-volume surgeons and hospitals performing coronary artery bypass grafting have been associated with improved patient outcomes. However, patients of increased socioeconomic distress may have worse outcomes because of health care disparities. We sought to identify trends and outcomes in patients of elevated distress undergoing bypass grafting. MethodsThe Florida Agency for Healthcare Administration administrative data set was merged with Centers for Medicare and Medicaid Services Physician and Hospital Compare and Economic Innovation Group Distressed Community Index data sets to build a comprehensive database. The data set was queried to identify patients undergoing coronary artery bypass procedures between 2016 and 2020. High- and low-volume hospitals and surgeons were compared. Patient and hospital demographics, comorbidities, length of stay, and postoperative complications were analyzed by χ2 and t test where appropriate. ResultsA total of 41,571 coronary artery bypass grafting procedures were performed by 174 surgeons at 67 Florida hospitals. Low- and high-volume hospitals did not differ with respect to hospital ownership, overall star rating, national comparisons of mortality, readmission, or cost effectiveness. Patients from at-risk and distressed communities were more likely to undergo surgery at low-volume hospitals. Hospital length of stay was increased for low-volume hospitals (10.2 vs 9.4 days, P < .05). Postoperative complications including pneumonia, arrhythmia, respiratory failure, acute renal failure, shock, pleural effusion, and sepsis were more frequent at low-volume hospitals and for low-volume surgeons. ConclusionHigh-volume hospitals and surgeons have improved postoperative outcomes and hospital length of stay when compared to low-volume hospitals and surgeons performing coronary artery bypass grafting. At-risk and distressed populations are more likely to undergo bypass surgery at low-volume hospitals, potentially contributing to worse patient outcome. Efforts should be made to mitigate the potential impact of low socioeconomic status to improve outcomes in this population.

Role Of Transperineal Ultrasound In Assessment Of Fetal Head Engagement As Indication Of Caesarean Section Taking Mode Of Delivery As Gold Standard

The frequency of caesarean sections has been gradually increasing in the past several decades. The usage of transperineal ultrasound (TPU) has been increasing. Many studies have demonstrated that TPU can provide valuable information for the clinician. Objective: To assess the role of transperineal ultrasound in fetal head engagement as indication of caesarean section taking mode of delivery as gold standard. Methods: A cross-sectional study was carried out in Radiology Department of Nawaz Medicare and DHQ hospital, Faisalabad. Written consent was taken from all patients before the ultrasound examination. Patients were assessed for eligibility in inclusion criteria. Confirmation of intrauterine living pregnancy, placenta site, fetal presentation, liquor amount and gestational age was done with routine obstetric ultrasound. Enrolled pregnant patients at term were assessed for the fetal head-perineal distance and cervical length by TPU examination. Results: One hundred and twenty-four (124) women participated in the investigation. Maternal age and gestational age were not determinants of outcomes of labor. Fetal head-perineal distance measured by TPU had a test sensitivity of 88.31 %, specificity of 78.72 %, the positive predictive value is 87.18%, the negative predictive value is 80.43% and diagnostic accuracy is 84.68%. Conclusions: The findings of this study shows that head perineal distance measured by TPU have higher sensitivity and is a non-invasive method which provides valuable objective measurements for fetal head engagement in primigravida at term and can be easily accepted and tolerated by women. Also, unnecessary caesarean section rate can be reduced by timely decision.

Impact of Reengineered Discharge Toolkit on Patients Undergoing Total Joint Surgeries.

Poorly coordinated care transitions account for nearly one fifth of Medicare hospital readmissions within 30 days postdischarge. The primary aim of this pilot project was to determine the impact of the Reengineered Discharge (RED) Toolkit on patient knowledge for self-management, satisfaction with the discharge process, readiness for discharge, discharge time, and 30-day readmission rate following hip or knee joint replacement or revision surgeries. Staff adherence with the RED Toolkit was also measured.Thirty adult patients received the intervention of the RED Toolkit. Patient knowledge for self-management ranged from 85.2% to 92.6%; satisfaction with the discharge process scores increased from 33% to 59.2%; patient readiness for discharge scores increased from 2% to 64%. Discharge times decreased. On average, patients left the unit 5.67 (±2.52) hours after the written discharge order. The all-cause 30-day readmission rate was reduced to 3.3%. Staff achieved a RED Toolkit adherence rate of 86.8%. Findings provide a basis for developing a coordinated discharge planning process.

Correlation between innate and adaptive immunity response in TB children post BCG vaccination. Is it effective or not?: Cross-sectional study

BackgroundHow far the role of innate immunity and adaptive immunity do in children who have been BCG vaccinated in controlling the course and the severity of the TB disease has not been completely known. Mycobacterium tuberculosis entry to the body will be recognized by Toll-like receptors found on macrophages, neutrophils, and dendritic cells as part of the innate immune response, after which the dendritic cells will then present the antigen to lymphocyte T0 cells and initiate the adaptive immune response (of which CD4 T cells have an important role in). Was one or were both of these immune responses function well or not in a BCG Vaccinated Children with TB? ObjectiveThis study aim to find a better understanding of the role of innate immune response assessed by TLR2/TLR4 mRNA gene expression and serum TLR2/TLR4 levels, while the role of adaptive immune response is assessed by analyzing serum CD4 level in children with TB who have had BCG vaccination. MethodsThis cross-sectional study was conducted among children with TB at the outpatient and inpatient wards at Bhakti Medicare and Jakarta Islamic Hospital. Expression of mRNA gene was measured using the Boom method and protein serum levels were measured using the ELISA method. The results were analyzed by using the SPSS v.23 program. ResultsSixty-nine children were recruited as subjects. In this study, 68.1% of whom had BCG scars. TLR4 mRNA gene expression was found to be higher than TLR2 mRNA gene expression. Serum CD4 level was found to be highest out of TLR2 and TLR4 level, but serum TLR2 level was higher than TLR4 level. TLR2/TLR4 mRNA gene expression, serum TLR2/TLR4 levels, and CD4 levels in subjects with BCG scar were also found to be significantly higher than in subjects without BCG scar (p < 0.001). There was a significant positive correlation between TLR2/TLR4 mRNA gene expression and serum TLR2/TLR4 levels (r = 0.860; r = 0.864; p < 0.001) and between serum levels TLR2/TLR4 with serum CD4 levels (r = 0.822; r = 0.832 p < 0.001). ConclusionAs early as possible, BCG vaccine administration is needed in endemic countries, but it must be ensured that scars can be formed. It is also important to control Latent TB Infection (LTBI) to prevent transmission and relapse of disease.

Sociodemographic Disparities in Access to Chemotherapy for Bladder Cancer.

We sought to evaluate sociodemographic disparities in access to neoadjuvant (NAC) and adjuvant (AC) chemotherapy in the United States and their effect on survival. The National Cancer Database was used to identify all patients from 2004 to 2016 eligible for NAC and AC. Univariate and multivariate logistic regression was performed to identify sociodemographic predictors associated with receipt of NAC and AC. Kaplan-Meier and Cox proportional hazard models were used for survival analysis. A total of 17,121 patients were eligible for NAC, and 18,962 for AC. Older (OR 0.94, P < .001), Medicare (OR 0.88, P=.047), Medicaid (OR 0.66, P=.001), uninsured (OR 0.47, P < .001), rural (OR 0.70, P=.042), and community hospital patients (OR 0.72, P < .001) were less likely to receive NAC. Older, (OR 0.95, P < .001), female (OR 0.79, P < .001), Medicaid (OR 0.71, P=.003), uninsured (OR 0.60, P=.001), and lower income patients (OR 0.86, P=.017) were less likely to receive AC. In NAC-eligible patients, older (HR 1.02, P < .001), Medicare (HR 1.11, P=.024), Medicaid (HR 1.25, P=.012), and community hospital patients (HR 1.09, P=.021) were at an increased risk of death. In AC-eligible patients, older (HR 1.01, P < .001), Black (HR 1.15, P=.011), Medicaid (HR 1.14, P=.042), lower income (HR 1.07, P=.038) and community hospital patients (HR 1.07, P=.021) were at an increased risk of death. Significant sociodemographic disparities currently exist in the United States in access to neoadjuvant and adjuvant chemotherapy for bladder cancer. Uninsured and Medicaid insurance status are the strongest predictors of not receiving chemotherapy. Efforts must be made to deliver this critical standard-of-care treatment to these patients.

Social risk adjustment in the hospital readmission reduction program: Pitfalls of peer grouping, measurement challenges, and potential solutions.

To examine the limitations of peer grouping and associated challenges measuring social risk in Medicare's Hospital Readmission Reduction Program (HRRP). Under peer grouping, hospitals are divided into quintiles based on the proportion of a hospital's Medicare inpatients with Medicaid ("dual share"). This approach was implemented to address concerns that the HRRP unfairly penalized hospitals that disproportionately serve disadvantaged patients. Public data on hospitals in the HRRP. We examined the relationship between hospital dual share and readmission rates within peer groups; changes in hospitals' peer group assignments, readmission rates, and penalties; and the relationship between state Medicaid eligibility rules and peer groups. Public data on hospital characteristics and readmission rates for 3119 hospitals from 2019 to 2020. The proportion of dual inpatients among hospitals of the same peer group varied by as much as 69 percentage points (ppt). Within peer groups, a one ppt increase in dual share was associated with a 0.01 ppt increase in the difference from the median readmission rate (p< 0.001). From 2019 to 2020, 8.8% of hospitals switched peer groups. Compared to hospitals that did not switch, those moving to a lower peer group had a higher mean penalty in 2020 (0.096 ppt; p=0.006); those moving to a higher group had a lower mean penalty (-0.06 ppt; p=0.079). However, changes in penalties did not correspond to changes in readmission rates. Hospitals in states with higher Medicaid income eligibility limits were more likely to be in higher peer groups. Peer grouping is limited in the extent to which it accounts for differences in hospitals' patient populations, and it may not fully insulate hospitals from penalties linked to changes in patient mix. These problems arise from the construction of peer groups and the measure of social risk used to define them.

Public reporting for coronary artery bypass graft surgery: The quest for the optimal scorecard

ObjectiveA number of publicly available rating algorithms are used to assess hospital performance in coronary artery bypass grafting (CABG). However, concerns remain that these algorithms fail to correlate with each other and inadequately capture the case complexity of individual center practices. MethodsComposite star ratings for isolated CABG from the Society of Thoracic Surgeons public reporting database were extracted for 2018-2019. U.S. News & World Report Best Hospitals was used to extract CABG ratings as well as overall cardiology and heart surgery ranking, and the Centers for Medicare & Medicaid Services Hospital Compare was used to extract CABG volume and 30-day mortality. Spearman correlation coefficients were used to assess possible relationships. Expert opinion on risk adjustment and program evaluation was incorporated. ResultsCorrelations between Society of Thoracic Surgeons star rating and U.S. News & World Report overall ranking in cardiology and heart surgery (r = 0.15) and Centers for Medicare & Medicaid Services 30-day mortality (r = −0.27) were poor. Society of Thoracic Surgeons star rating correlated weakly with U.S. News & World Report CABG ratings (r = 0.33) and with Centers for Medicare & Medicaid Services CABG volume (r = 0.32), whereas the latter 2 correlated moderately (r = 0.52) with each other. Of the 75 centers with accredited cardiac surgery training programs, 13 (17%) did not participate in Society of Thoracic Surgeons public reporting. Important gaps were identified in risk assessment, and potential solutions are proposed. ConclusionsCorrelations between current CABG public reporting systems are weak. Further work is needed to refine and standardize CABG rating systems to more adequately capture the scope and complexity of an individual center's clinical practice and to better inform patients.