Payer Status Research Articles

Proportional Trends in Pediatric Opioid Prescribing Between 2005 and 2016 by Age Group, Sex, Ethnicity, Race, Language, and Payer Status from a Large Children’s Hospital in the Southwest United States

Background/Objectives: Prescription opioid use before adulthood is typically effective for acute pain control and is also associated with adverse short- and long-term consequences. Methods: This study examined pediatric opioid prescribing trends over time across different age groups (early childhood, school age, adolescence, young adult) and sociodemographic subgroups (sex, ethnicity, race, language, payer type) from 2005 to 2016. Results: Utilizing 42,020 first outpatient opioid prescriptions for youth aged 0–21 years from a large US children’s hospital, this research found notable trends and disparities. Prescription rates increased by 35% from 2005–2007 to 2008–2010, then decreased by 14% from 2008–2010 to 2011–2013, and decreased again by 22% from 2011–2013 to 2014–2016. Chi-squared tests indicated significant changes in prescription rates across all sociodemographic subgroups, though only age group, ethnicity, and payer type (i.e., the party responsible for payment for hospital services) had changes with non-negligible effect sizes (Cramer’s V). Specifically, age group showed small to medium effects (V = 0.16), while ethnicity and payer demonstrated small effects (V = 0.10 each). This study highlights variations in opioid prescribing trends, particularly among different age groups, ethnicities, and payer statuses up to 2016. Conclusions: These findings reveal differing trends in pediatric opioid prescribing during the peak of the opioid epidemic, highlighting the importance of considering age and sociodemographic variables for understanding prescribing patterns fully and raising potential concerns about inequities in pain management. Future studies should explore similar trends from 2016 onward.

Comparing imputation approaches for immigration status in ED visits: Implications for using electronic medical records.

This study aimed to compare imputation approaches to identify the likely undocumented patient population in electronic health record (EHRs). EHR are a promising source of information on undocumented immigrants' medical needs and care utilization, but there is no verified way to identify immigration status in the data. Different approaches to approximating immigration status in EHR introduce unique biases, which in turn has major implications on our understanding of undocumented immigrant patients. We used a dataset of all emergency department (ED) visits from 2016 to 2019 in the Los Angeles Department of Health Services (LADHS) merged across patient medical records, demographic data, and claims data. We included all ED visits from our patient groups of interest and limited to patients at or over the age of 18 years at the time of their ED visit and excluded empty encounter records (n = 1,106,086 ED encounters). We created three patient groups: (1) US-born, (2) foreign-born documented, and (3) undocumented using two different imputation approaches: a logical approach versus statistical assignment. We compared predicted probabilities for two outcomes: an ED visit related to a behavioral health (BH) disorder and inpatient admission/transfer to another facility. Both approaches provide comparable estimates among the three patient groups for ED encounters for a BH disorder and inpatient admission/transfer to another facility. Undocumented immigrants are less likely to have a BH diagnosis in the ED and are less likely to be admitted or transferred compared to the US-born. Researchers should consider expanding EHR with administrative data when studying the undocumented patient population and may prefer a logical approach to estimate immigration status. Researchers who rely on payer status alone (i.e., restricted Medicaid) as a proxy for undocumented immigrants in EHR should consider how this may bias their results. As Medicaid expands for undocumented immigrants, statistical assignment may become the preferred method.

Preoperative Depression is Associated With a Higher Risk of Bleeding in Type a Aortic Dissection Repair: A Population Study of National Inpatient Sample From 2015-2020.

Depression is highly prevalent in patients with aortic diseases. While depression has been shown to predispose patients to adverse outcomes after surgery, its impact on postoperative outcomes in Stanford Type A Aortic Dissection (TAAD) has not been established. This study aimed to conduct a population-based examination of the effect of preoperative depression on in-hospital outcomes after TAAD using the National/Nationwide Inpatient Sample (NIS) database, the largest all-layer database in the US. Patients undergoing TAAD repair were identified in NIS from the last quarter of 2015-2020. Multivariable logistic regressions were used to compare in-hospital outcomes between patients with and without preoperative depression, adjusted for demographics, comorbidities, hospital characteristics, primary payer status, and transfer status. There were 321 (7.50%) patients with depression and 3961 (92.50%) non-depressive patients who underwent TAAD repair. Patients with and without depression had comparable in-hospital mortality (11.84% vs 15.37%, P = 0.35). However, Patients with depression had a higher risk of hemorrhage/hematoma (83.49% vs 76.6%, aOR 1.593, 95 CI 1.161-2.184, P < 0.01) and a higher rate of transfer out (40.81% vs 32.62%, aOR 1.396, 95 CI 1.077-1.81, P = 0.01). All other in-hospital complications, hospital length of stay (LOS), and total hospital charge were comparable between patients with and without depression. Preoperative depression is associated with a higher risk of bleeding after TAAD repair. This may be due to anti-depression treatment, such as Selective Serotonin Reuptake Inhibitors (SSRIs), that can disrupt platelet function and lead to abnormal bleeding. While depression is not associated with other major outcomes, preoperative depression screening, as well as hemostatic monitoring and appropriate blood management in patients with depression may be crucial in preventing bleeding complications in TAAD repair.

Robotic availability, not payor status, determines access to robotic emergency general surgery hernia repair in California and Florida.

Previous studies have demonstrated that access to robotic surgery is influenced by socioeconomic factors, including insurance status. The 2010 Affordable Care Act established an avenue for states to expand Medicaid coverage, which has increased access to surgical care for many conditions. We hypothesized that socioeconomic disparities in access to robotic repair of non-elective emergency general surgery (EGS) hernias are less prevalent in California, a Medicaid expansion state, compared to Florida, which has not adopted Medicaid expansion. The 2021 California and Florida State Inpatient Databases were used to identify all EGS admissions with an ICD-10 procedure code for ventral or inguinal hernia repair. Elective procedures and those with concurrent unrelated abdominal procedures were excluded. Patient demographics, comorbidity burden, payor status, and income quartile were abstracted. Aggregation of hospital data identified high-volume trauma, robotic, and EGS centers. There were 15,683 EGS hernia procedures of which 11% underwent robotic repair: 14% in Florida and 8% in California. On multivariable logistic regression, older age, male sex, lower income, and Medicare insurance were associated with reduced odds of robotic hernia repair in California, but not in Florida, despite an uninsured rate of 10%. The greatest predictor of robotic surgery in both states was treatment at a robotic surgery center. Overall, accounting for patient- and hospital-level factors, hernia surgeries in Florida were more likely to involve robotics (OR 1.61, CI 1.42-1.81, p < 0.001) compared to California. There were fewer disparities in access to EGS robotic hernia repairs in Florida than in California. This suggests that robotic surgery access for EGS hernia repairs is primarily determined by institutional adoption of robotic surgery, not income or payor status. Compared to California, Florida appears to have greater market penetration of robotic surgery, which has increased access to robotic EGS for all patients.

Hospital and Patient Factors Associated with Length of Hospitalization in Patients Who Have Osteoarthritis Undergoing Primary Total Knee Arthroplasty: An Analysis of National Data

Background/Objective: By 2040, an estimated 3.5 million primary total knee arthroplasties (TKAs) will be performed each year in the United States (U.S.) osteoarthritis (OA) is the most common indication for primary TKA. We examined the association of hospital, regional, and patient-level factors with extended lengths of hospital stay (eLOS). MethodsPatients who have OA who underwent primary TKA from 2016 to 2019 were queried using a national inpatient database. We used the International Classification of Disease (ICD-10) codes to identify diagnoses and procedures. There were 2,592,469 patients who had OA who underwent primary TKA from 2016 to 2019. We used univariate and multivariable-adjusted logistic regression analyses to assess whether patient, payer, hospital, and geographic factors were associated with an eLOS. Predictive probabilities from multivariable analyses were used in the Area Under the Curve (AUC) analysis. ResultsPatient race and ethnicity, Medicaid or Medicare payer status, income, age/sex, and nearly all regional and hospital characteristics were independently associated with eLOS (> 3 days; ROC C-statistic = 0.74). Sensitivity analyses that used the most recent years of data from 2020 to 2021 (COVID-19 pandemic years), or adjusted for individual organ system complications reproduced the main results without much attenuation. ConclusionAge, sex, race, ethnicity, hospital location and teaching status, elective procedure designation, perioperative complications, and insurance payer status significantly influenced the length of hospital stay (LOS) for primary total knee arthroplasty (TKA) hospitalizations in the US. Recognized disparities were linked to longer hospital stays after primary TKA in patients who had osteoarthritis (OA). Implementing policies and interventions that target these factors could help shorten hospital stays for high-risk patients after primary TKA.

Factors associated with colon cancer fragmentation in the Keystone state.

120 Background: Fragmentation of cancer care delivery across multiple providers can impact care quality and patient outcomes. Management of non-metastatic colon cancer often involves adjuvant chemotherapy, which increases the risk of potentially deleterious care dispersion. This study assesses the extent of care fragmentation across different inpatient facilities and examines patient characteristics associated with inpatient care fragmentation. Methods: We adapt the modified Herfindahl-Hirschman market concentration index to construct a Fragmentation Index (FI) capturing the distribution of a patient’s care across inpatient facilities. For patients who underwent oncologic surgery for colon cancer from 2010-2016, we calculate FI for the 15 months post-diagnosis if at least 2 admissions occur during the study period. We use Pennsylvania Cancer Registry data linked to all-payer statewide facility discharge records to estimate the relationship between FI and patient demographics, rurality, area deprivation index (ADI), and payer status using adjusted multivariable linear regression models. Results: For the operative cohort (28.6% Stage I, 34.7% Stage II, 36.7% Stage III, n = 7803), 86% of patients lived in urban areas, 9.5% in large towns and 5% in rural areas. 60% had Medicare, 6.1% Medicaid and 7.1% were uninsured or had unknown payer status. 52% of patients were female and 87% were non-Hispanic White. The overall mean FI was 0.192; 60% (n = 4693) had an FI of 0, indicating all admissions were at the same hospital, and among those with FI&gt; 0 (n = 3110), mean FI was 0.483. The mean FI for patients potentially eligible for adjuvant chemotherapy (Stage II, III) was 0.188: 61% of patients had an FI of 0 and among those with FI &gt; 0 (n = 2173), mean FI was 0.482. Stratification by stage reveals similar proportions of FI &gt; 0.5 (stage I: 24.6%, stage II: 22.3%, stage III: 21.3%). Increased care dispersion was observed in patients from large towns (ΔFI 0.04, CI 0.03—0.06) or rural areas (ΔFI 0.04, CI 0.02—0.08) relative to urban areas, as well as for patients with relatively higher number of hospitalizations (ΔFI 0.04, CI 0.03—0.04). Less care dispersion was seen in patients with stage III disease (relative to stage I ΔFI -0.02, CI -0.03 — -0.01), uninsured status (relative to private insurance ΔFI -0.03, CI -0.05 – -0.01) or residence in the most disadvantaged ADI quartile (relative to Q1 ADI ΔFI -0.02, CI -0.04 — 0.00). Conclusions: Among patients with operatively managed colon cancer, slightly more than half did not experience inpatient care fragmentation. As expected, a higher number of total admissions and non-urban residence were associated with increased inpatient care dispersion. However, our findings of more concentrated care among patients with stage III disease, higher levels of relative economic disadvantage, and uninsured status suggest potentially complex and divergent forces driving hospital selection, to be explored in future work.

Smaller Hospital Size is Associated With Higher Mortality in Stanford Type A Aortic Dissection.

Stanford Type A Aortic Dissection (TAAD) is associated with high in-hospital mortality and the need for immediate surgical intervention. Larger hospital size may be associated with better patient care and surgical outcomes. This study aimed to examine the effect of hospital size on TAAD outcomes. Patients who underwent TAAD repair were identified in National Inpatient Sample (NIS) from Q4 2015-2020. NIS stratifies hospital size into small, medium, and large based on the number of hospital beds, geographical location, and the teaching status of the hospitals. Patients admitted to small/medium and large hospitals were stratified into two cohorts. Multivariable logistic regressions were performed to compare in-hospital outcomes, adjusted for demographics, comorbidity, primary payer status, and hospital characteristics including procedural volume. There were 1106 and 3752 TAAD admitted to small/medium and large hospitals, respectively. Among patients admitted to small/medium hospitals, there was higher mortality (17.27% vs 14.37%, aOR = 1.32, P < 0.01), but shorter length of stay (P < 0.01) and lower cost (P = 0.03) compared to larger hospitals. There was no difference in morbidities. Marked higher mortality is associated with admission to smaller hospitals among patients with TAAD, which may in turn decrease the average hospital stay and cost. Given that a significant percentage of patients are already being transferred out of the initial hospital and small/medium hospital is associated with higher mortality, centralization of care in centers of excellence may decrease the high mortality associated with TAAD.

Evaluating outcomes of transjugular intrahepatic portosystemic shunt procedure among Native Americans

BackgroundThis study aims to explore racial disparities in immediate outcomes of Transjugular Intrahepatic Portosystemic Shunt (TIPS) among Native Americans, a group that have higher prevalence of liver cirrhosis but were the “invisible group” in previous TIPS studies due to their small population size. MethodsThe study identified Native Americans and Caucasians who underwent TIPS in National/Nationwide Inpatient Sample (NIS) database from Q4 2015–2020. Preoperative factors, including demographics, indications for TIPS, comorbidities, etiologies for liver disease, primary payer status, and hospital characteristics, were matched by 1:5 propensity score matching. In-hospital post-TIPS outcomes were then compared between the two cohorts. ResultsThere were 6,658 patients who underwent TIPS, where 101 (1.52 %) were Native Americans and 4,574 (68.70 %) were Caucasians. Native Americans presented as younger, with a lower socioeconomic status, and displayed higher rates of alcohol abuse and related liver diseases. After propensity-score matching, Native Americans had comparable in-hospital post-TIPS outcomes including mortality (8.33% vs 9.09 %, p = 1.00), hepatic encephalopathy (18.75% vs 25.84 %, p = 0.19), acute kidney injury (28.13% vs 30.62 %, p = 0.71), and other adverse events. Native Americans also had similar wait from admission to operation (2.15 ± 0.30 vs 2.87 ± 0.21 days, p = 0.13), hospital length of stay (7.43 ± 0.63 vs 8.62 ± 0.47 days, p = 0.13), and total costs (158,299 ± 14,218.2 vs 169,425 ± 8,600.7 dollars, p = 0.50). ConclusionNative Americans had similar immediate outcomes after TIPS compared to their propensity-matched Caucasians. While these results underscore effective healthcare delivery of TIPS to Native Americans, it is imperative to pursue further research for long-term post-procedure outcomes.

P127. Impact of primary payer status and socioecoomic disparities in elective lumbar fusion surgery

P127. Impact of primary payer status and socioecoomic disparities in elective lumbar fusion surgery

Is Insurance Payor Associated With Hospital Admission of Emergency Department Adult Patients With Odontogenic Infections?

Patients who present to the emergency department (ED) with severe odontogenic infections are often hospitalized for surgical drainage and medical management. However, inpatient management of these patients can be financially burdensome. While medical indications for hospital admission are well established, it remains unclear if patient insurance status is associated with admission. The purpose of this study was to determine the nationally representative estimates of the incidence of hospital admission for patients with odontogenic infections and the association with insurance payor. This retrospective cohort study used the 2018 Nationwide Emergency Department Sample. Patients with odontogenic infections (based on International Classification of Diseases, 10th Revision codes) were included. Patients aged <18years or who had missing data were excluded. The primary predictor variable was primary payor (private insurance, Medicare, Medicaid, self-pay, and other). The primary outcome variable was hospital admission (yes/no). Covariates included sociodemographic, medical, infection, and hospital variables. Descriptive, bivariate, and multivariable logistic regression analyses were used to determine national estimates and predictors of admission. Odds ratios and 99% confidence intervals were computed. Discharge weights were accounted for in all analyses to provide nationally representative estimates. This study included 31,221 weighted ED encounters, of which 10,451 (33.5%) were admitted. In the study cohort, 7,687 (24.6%) had private insurance, 5,046 (16.2%) had Medicare, 10,070 (32.3%) had Medicaid, 7,436 (23.8%) were self-pay, and 982 (3.1%) had other. Bivariate analysis suggested that payor status was significantly associated with hospital admission (P<.01). The multivariable analysis showed that self-pay patients had significantly lower odds of hospital admission compared to those with private insurance (odds ratio, 0.54; 99% confidence interval, 0.42-0.70). Other independent predictors of hospital admission included infection in more than 1 location based on International Classification of Diseases, 10th Revision code, higher Charlson comorbidity index, and alcohol/substance use disorders. Approximately one-third of patients presenting to the ED with odontogenic infections were admitted. Patients with no insurance were less likely to be admitted compared to those with private insurance. This finding may reflect multiple possibilities, including hospital financial incentives.

Quantifying the association between doula care and maternal and neonatal outcomes

BackgroundThe US suffers from an increasing rate of severe maternal morbidity, paired with a wide disparity in maternal health by race. Doulas are posited to be a useful resource to increase positive outcomes and decrease this disparity. ObjectiveEvaluate the association of doula care with a broad range of maternal and neonatal outcomes in various subpopulations. Study DesignRetrospective cohort of deliveries from 1/2021-12/2022 at a single institution receiving prenatal care. Exposure was receipt of doula care prenatally and at delivery. We evaluated both maternal (cesarean delivery, cesarean delivery of nulliparous, term, singleton, vertex infant, vaginal birth after cesarean (VBAC), gestational hypertension, preeclampsia, postpartum emergency department visit, readmission and attendance at postpartum office visit) and neonatal (neonatal intensive care unit admission, unexpected complications in term newborns, breastfeeding, preterm delivery, and intrauterine fetal growth restriction) outcomes. Because our institution previously employed targeted outreach, offering doula services to patients at highest risk, we utilized multiple methods to generate an appropriate comparison population. We conducted multivariate logistic regression and conditional regressions using propensity scores, modeling likelihood of doula care, to generate adjusted risk differences associated with doula care. Analyses were repeated in populations stratified by race (White/Black) then payor status (public/commercial). ResultsOur cohort included 17,831 deliveries; 486 with doula care and 17,345 without. Patients receiving doula care were more likely to self-report Black race, be publicly insured, and live in a more disadvantaged neighborhood. Regardless of analytic approach, for every 100 patients under doula care there were 15-34 more VBACs [adjRD 15.6 (95%CI: 3.8, 27.4); adjRD 34.2 (95%CI: 0.046, 68.0)] and 5-6 more patients attending a postpartum office visit [adjRD 5.4 (95%CI: 1.4, 9.5); adjRD 6.8 (95% CI:3.7, 9.9)] compared with those not receiving doula services.Infants born to these patients were 20% more like likely to be exclusively breastfed [adjRR 1.22 (95%CI: 1.07, 1.38)], and doula care was associated with 3-4 fewer preterm births [adjRD -3.8 (95%CI: -6.1, -1.5); -4.0 (95%CI: -6.2, -1.8)] for every 100 deliveries receiving doula care. Results were consistent regardless of race or insurance. Results were also consistent when doula care was redefined as having at least 3 prenatal encounters with a doula. ConclusionsDoula care was associated with more VBACs, attendance at postpartum office visit, breastfeeding, and fewer preterm deliveries. The effect of doula care was consistent across race and insurance status.

The Society of Thoracic Surgeons 2024 Risk Models for Lung Cancer Resection: Continued Refinement and Improved Outcomes

BackgroundThe Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) has been used to develop risk models for patients undergoing pulmonary resection for cancer. Leveraging a contemporary and more inclusive cohort, this study sought to refine these models. MethodsThe study population consisted of adult patients in the STS GTSD who underwent pulmonary resection for cancer between 2015 and 2022. Unlike in previous models, nonelective operations were included. Separate risk models were derived for operative mortality, major morbidity, and composite morbidity or mortality. Logistic regression with backward selection was used with predictors retained in models if P < .10. All derived models were validated using 9-fold cross-validation. Model discrimination and calibration were assessed for the overall cohort and for surgical procedure, demographic, and risk factor subgroups. ResultsData from 140,927 patients at 337 participating centers were included in the study. Overall operative mortality rate was 1.1%, major morbidity was 7.3%, and composite morbidity or mortality was 7.6%. Novel predictors of short-term outcomes included interstitial lung disease, diffusing capacity of lung for carbon monoxide, and payer status. Overall discrimination was superior to previous STS pulmonary resection models for operative mortality (C-statistic = 0.80) and for composite morbidity or mortality (C-statistic = 0.70). Model discrimination was comparable and model calibration was excellent across all procedure- and demographic-specific subcohorts. ConclusionsAmong STS GTSD participants, major morbidity and operative mortality rates remained low after pulmonary resection. The newly derived pulmonary resection risk models demonstrate superior performance compared with previous models, with broader real-life applicability and clinical face validity.

Peripheral artery disease is an independent risk factor for higher in-hospital mortality in Stanford type A aortic dissection repair.

Type A aortic dissection (TAAD) is an emergent condition that warrants immediate intervention. Peripheral artery disease (PAD) is a prevalent disease associated with worse outcomes in various cardiovascular procedures. However, it remains unclear whether PAD influences outcomes of TAAD repair. This study aimed to undertake a population-based analysis to assess impact of PAD on in-hospital outcomes following TAAD repair. Patients underwent TAAD repair were identified in National Inpatient Sample from Q4 2015 to 2020. Multivariable logistic regressions were used to compare in-hospital outcomes between patients with and without PAD, adjusted for demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and transfer/admission status. 1525 patients with PAD and 2757 non-PAD patients underwent TAAD. PAD patients had higher mortality (18.62% vs 13.17%, aOR = 1.287, p = .01), AKI (51.41% vs 47.48%, aOR = 1.222, p < .01), infection (10.69% vs 8.02%, aOR = 1.269, p = .03), and vascular complication (7.28% vs 3.77%, aOR = 1.846, p < .01) but lower risks of pericardial complications (15.21% vs 19.95%, aOR = 0.696, p < .01). In addition, patients with PAD had longer time from admission to operation (1.29 ± 3.95 vs 0.70 ± 2.09 days, p < .01), longer LOS (14.92 ± 13.98 vs 13.41 ± 11.66 days, p = .01), and higher hospital charge (499,064 ± 519,405 vs 409,754 ± 405,663 US dollars, p < .01). PAD was independently associated with worse outcome after TAAD repair. The elevated mortality rate could be attributed to the delay in surgery, which may be related to preoperative peripheral malperfusion syndrome that is common in PAD patients. A balance between preoperative management and immediate TAAD repair might be essential to prevent the increased mortality risk from treatment delays among PAD patients.

Sustainability and Dividends: Complements or Substitutes?

We examine the relationship between environmental, social, and governance commitment levels (ESG) and firm dividend-payer status. Given that larger and more profitable firms are positively associated with both payer status and ESG, it could be that ESG and dividends are complements. However, given that both dividends and ESG relate to firm spending decisions, it may be that the choice is “either/or”, and that ESG and dividends are substitutes. We document a positive relationship between ESG and dividend-payer status in U.S. firms over the period 1991–2016. In particular, we find that the proportion of dividend-payers is roughly 13% higher for firms with positive ESG compared to those with negative ESG. Including ESG in the models used to predict payer status provides, on average, a nearly 26% improvement in relative forecast accuracy. Our results are robust in regards to estimation techniques and the inclusion of variables known to be determinants of payer status. The results indicate that, on average, firms are not forced to sacrifice dividends in favor of ESG spending.

Alcohol use disorder is associated with a lower risk of in-hospital mortality in type A aortic dissection repair: a population-based study of National Inpatient Sample from 2015-2020.

While alcohol consumption is implicated in the development of aortic dissection, the impact of alcohol use disorder (AUD) on the outcomes of type A aortic dissection (TAAD) repair is still largely unexplored. This study aimed to conduct a comprehensive, population-based analysis of effect of AUD on in-hospital outcomes following TAAD repair using National/Nationwide Inpatient Sample, the largest all-payer database in the United States. Patients undergoing TAAD repair were identified in National/Nationwide Inpatient Sample from Q4 2015-2020. Demographics, comorbidities, hospital characteristics, primary payer status, and transfer-in status between patients with and without AUD were matched by a 1:3 propensity-score matching. In-hospital outcomes were examined. There were 220 patients with AUD who underwent TAAD repair. Meanwhile, 4062 non-AUD patients went under TAAD repair, where 646 of them were matched to all AUD patients. After propensity-score matching, AUD patients had a lower risk of in-hospital mortality (7.76% vs 13.31%, P = 0.03) while there was no difference in transfer-in status or time from admission to operation. However, patients with AUD had a higher rate of respiratory complications (27.40% vs 19.66%, P = 0.02) and a longer hospital length of stay (16.20 ± 11.61 vs 11.72 ± 1.69days, P = 0.01). All other in-hospital outcomes were comparable between AUD and non-AUD patients. AUD patients had a lower risk of in-hospital mortality but a higher rate of respiratory complications and a longer LOS. These findings can provide insights into preoperative risk stratification of these patients. Nonetheless, reasons underlying the lower mortality rate in AUD patients and their long-term prognosis require further investigation.

Payer Status and Racial Disparities in Time to Surgery for Emergent Orthopaedic Procedures.

Delay in surgical management for orthopaedic emergencies and severe fracture types can result in notable morbidity and even mortality for patients. Disparities in various facets of orthopaedic care have been identified based on race/ethnicity, socioeconomic status, and payer status, but disparities in time to surgery have been poorly explored. The purpose of this study was, therefore, to investigate whether disparities exist in time to emergent orthopaedic surgery. Patients who underwent surgery for hip fracture, femur fracture, pelvic fracture, septic knee, septic hip, or cauda equina syndrome over 2012 to 2020 were identified using national data. Multivariable linear regression models were constructed, controlling for age, sex, race/ethnicity, payer status, socioeconomic status, hospital setting, and comorbidities to examine the effect of payer status and race/ethnicity, on time to surgery. Over 2012 to 2020, 247,370 patients underwent surgery for hip fracture, 64,827 for femur fracture, 14,130 for pelvic fracture, 14,979 for septic knee, 3,205 for septic hip, and 4,730 for cauda equina syndrome. On multivariable analysis, patients with Medicaid experienced significantly longer time to surgery for hip fracture, femur fracture, pelvic fracture, septic knee, and cauda equina syndrome ( P < 0.05 all). Black patients experienced longer time to surgery for hip fracture, femur fracture, septic knee, septic hip, and cauda equina syndrome, and Hispanic patients experienced longer time to surgery for hip fracture, femur fracture, pelvic fracture, and cauda equina syndrome ( P < 0.05 all). The results of this study demonstrate that Medicaid-insured patients, and often minority patients, experience longer delays to surgery than privately insured and White patients. Future work should endeavor to identify causes of these disparities to promote creation of policies aimed at improving timely access to care for Medicaid-insured and minority patients. III.

Racial and Ethnic Disparities in Sacrocolpopexy Approach.

Racial inequity elevates risk for certain diagnoses and health disparities. Current data show disparities for Black women when comparing open versus minimally invasive hysterectomy. It is unknown if a similar disparity exists in surgical management of pelvic organ prolapse. The objective of this study was to determine whether racial or ethnic disparities exist for open abdominal versus minimally invasive sacrocolpopexy. Cross-sectional data of the Healthcare Cost and Utilization Project National Inpatient Sample and the Nationwide Ambulatory Surgery Sample for the year 2019 was used. Bivariate analysis identified demographic and perioperative differences between abdominal versus minimally invasive sacrocolpopexy, which were compared in a multivariable logistic regression. Forty-one thousand eight hundred thirty-seven patients underwent sacrocolpopexy: 35,820 (85.6%), minimally invasive sacrocolpopexy, and 6,016, (14.4%) abdominal sacrocolpopexy. In an unadjusted analysis, Black patients were more likely to undergo an abdominal sacrocolpopexy compared to non-Hispanic White patients (OR 2.14, 95% CI 1.16-3.92, P <0.01). Hispanic patients were more likely to undergo abdominal sacrocolpopexy compared to non-Hispanic White patients (OR 1.69, 95% CI 1.26-2.26, P <0.001). Other factors associated with abdominal sacrocolpopexy are zip code quartile, payer status, composite comorbidity score, hospital control, and hospital bed size. In the regression model, Black patients remained more likely to undergo abdominal sacrocolpopexy compared to those who identified as White (aOR 2, 95% CI 1.26-3.16, P < 0.003). Hispanic patients were more likely to undergo abdominal sacrocolpopexy compared to those who identified as White (aOR 1.73, 95% CI 1.31-2.28, P < 0.001). Abdominal sacrocolpopexy was more likely to occur in patients who identified as Black or Hispanic.

Concentration of High-Cost Head and Neck Cancer Surgical Patients.

Health care costs are disproportionately concentrated among a small number of patients. We sought to identify variables associated with high-cost patients and high hospital concentration of high-cost patients and to examine associations with short-term outcomes in head and neck cancer (HNCA) surgery. The Nationwide Inpatient Sample was used to identify 170,577 patients who underwent HNCA surgery in 2001-2011. High-cost patients were defined as patients whose costs of care were in the top decile, and high-concentration hospitals were defined as those whose percentage of high-cost patients was in the top decile. Multivariable regression was used to evaluate associations between cost and patient and hospital variables, postoperative complications, and in-hospital mortality. Costs associated with high-cost patients were 4.47-fold greater than the remaining 90% of patients. High-concentration hospitals treated 36% of all high-cost patients. High-cost patients were more likely to be non-white (OR = 2.08 [1.45-2.97]), have oral cavity cancer (OR = 1.21 [1.05-1.39]), advanced comorbidity (OR = 1.53 [1.31-1.77]), Medicaid (OR = 1.93 [1.62-2.31]) or self-pay payor status (OR = 1.72 [1.38-2.14]), income>50th percentile (OR = 1.25 [1.05-1.51]), undergo major procedures (OR = 3.52 [3.07-4.05]) and have non-routine discharge (OR = 7.50 [6.01-9.35]). High-concentration hospitals were more likely to be teaching hospitals (OR = 3.14 [1.64-6.05]) and less likely to be urban (OR = 0.20 [0.04-0.93]). After controlling for all other variables, high-cost patients were associated with an increased odds of mortality (OR = 8.00 [5.89-10.85]) and postoperative complications (OR = 5.88 [5.18-6.68]). High-concentration hospitals were associated with an increased odds of postoperative complications (OR = 1.31 [1.08-1.61]) but were not associated with increased mortality (OR = 0.98 [0.67-1.44]). High-cost HNCA surgical patients are associated with increased postoperative morbidity and mortality, and are disproportionately concentrated at teaching hospitals. 4 Laryngoscope, 2024.

Racial Disparities Exist in 90-Day Unplanned Return to the Emergency Department Following Orthopaedic Trauma Surgery.

Racial disparities in healthcare outcomes exist, including in orthopaedic trauma care. The aim of this study was to determine the impact of race, social deprivation, and payor status on 90-day emergency department (ED) revisits among orthopaedic trauma surgery patients at a Level 1 trauma academic medical center. Retrospective chart review analysis. Level 1 trauma academic center in Durham, NC. Adult patients undergoing orthopaedic trauma surgery between 2017 and 2021. The primary outcome of this retrospective cohort study was 90-day return to the ED. Logistic regression analysis was performed for variables of interest [race, social deprivation (measured by the Area Deprivation Index), and payor status] separately and combined, with each model adjusting for distance to the hospital. Results were interpreted as odds ratios (ORs) of 90-day ED revisits comparing levels of the respective variables. Statistical significance was assessed at α = 0.05. A total of 3120 adult patients who underwent orthopaedic trauma surgery between 2017 and 2021 were included in the analysis. Black race (OR = 1.47; 95% confidence interval [CI]: 1.17-1.84, P < 0.001) and Medicaid coverage (OR = 1.63, 95% CI: 1.20-2.21, P = 0.002) were significantly associated with higher odds of return to ED compared with non-Black or non-Medicaid-covered patients. While ethnic minority (Hispanic/Latino or non-White) was statistically significant while adjusting only for distance to the hospital (OR = 1.23, 95% CI: 1.00-1.50, P = 0.047), it was no longer significant after adjusting for the other sociodemographic variables (OR = 1.13, 95% CI: 0.91-1.39, P = 0.27). The weighted Area Deprivation Index was not associated with a difference in odds of return to ED in any adjusted models. The results highlight the presence of racial and socioeconomic disparities in ED utilization, with Black race and Medicaid coverage significantly associated with higher odds of return to the ED. Future research should delve deeper into comprehending the root causes contributing to these racial and socioeconomic utilization disparities and evaluate the effectiveness of targeted interventions to reduce them. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Payer Status and Medication Management-Part Six of the Movement Is Life Special ONJ Series.

This article is the sixth in the Movement is Life series and focuses on insurance coverage and medication management in the perioperative period, 2 tangentially related variables that affect patient outcomes. Our aim is to use current practices and literature to develop recommendations for nurse navigators' execution of preoperative optimization protocols related to payer status and medication management. Discussions with nurse navigators and a literature search were used to gather information and develop recommendations specific to optimizing payer status and medication management. Nurse navigators connected patients to resources and provided education regarding financial concerns and medications, and findings from the literature discussed insurance status among TJA patients. Nurse navigators can contribute to payer status and medication management optimization by providing patient education and resource referrals. In addition, we recommend conducting repeated medication reconciliation and developing awareness of financial resources and perioperative medication management guidelines.