Standard Analytic Files Research Articles

The public health burden of geriatric trauma: Analysis of 2,688,008 hospitalizations from Centers for Medicare and Medicaid Services inpatient claims.

Geriatric trauma care (GTC) represents an increasing proportion of injury care, but associated public health research on outcomes and expenditures is limited. The purpose of this study was to describe GTC characteristics, location, diagnoses, and expenditures. Patients at short-term nonfederal hospitals, 65 years or older, with ≥1 injury International Classification of Diseases, Tenth Revision, were selected from 2016 to 2019 Centers for Medicare and Medicaid Services Inpatient Standard Analytical Files. Trauma center levels were linked to Inpatient Standard Analytical Files data via American Hospital Association Hospital ID and fuzzy string matching. Demographics, care location, diagnoses, and expenditures were compared across groups. A total of 2,688,008 hospitalizations (62% female; 90% White; 71% falls; mean Injury Severity Score, 6.5) from 3,286 hospitals were included, comprising 8.5% of all Medicare inpatient hospitalizations. Level I centers encompassed 7.2% of the institutions (n = 236) but 21.2% of hospitalizations, while nontrauma centers represented 58.5% of institutions (n = 1,923) and 37.7% of hospitalizations. Compared with nontrauma centers, patients at Level I centers had higher Elixhauser scores (9.0 vs. 8.8) and Injury Severity Score (7.4 vs. 6.0; p < 0.0001). The most frequent primary diagnosis at all centers was hip/femur fracture (28.3%), followed by traumatic brain injury (10.1%). Expenditures totaled $32.9 billion for trauma-related hospitalizations, or 9.1% of total Medicare hospitalization expenditures and approximately 1.1% of the annual Medicare budget. The overall mortality rate was 3.5%. Geriatric trauma care accounts for 8.5% of all inpatient GTC and a similar percentage of expenditures, the most common injury being hip/femur fractures. The largest proportion of GTC occurs at nontrauma centers, emphasizing their vital role in trauma care. Public health prevention programs and GTC guidelines should be implemented by all hospitals, not just trauma centers. Further research is required to determine the optimal role of trauma systems in GTC, establish data-driven triage guidelines, and define the impact of trauma centers and nontrauma centers on GTC mortality. Therapeutic/care management, Level III.

Outcomes and Treatment Costs of Skilled Nursing Facility Patients with Pressure Injuries and Malnutrition

Skilled nursing facilities (SNF) provide care for individuals requiring skilled care while transitioning to a more permanent residence post hospitalization. This analysis shows that diagnosed malnutrition and pressure injuries (PI) adversely impact SNF patients’ health and recovery. Length of SNF stay, total charges, and discharge disposition were analyzed using SNF claims from 2016-2020 Centers for Medicare & Medicaid Services (CMS) Standard Analytical File databases. An average of 4.5% SNF patients had diagnosed PIs, and 4.9% had diagnosed malnutrition. Patients with diagnosed malnutrition were more likely to have PIs than patients without diagnosed malnutrition (11.9% vs 4.1%). Patients with PIs had higher charges ($12,304 vs. $10,937), were less likely to be discharged home (11.1% vs 18.9%), and more likely to be discharged to a hospital (15.8% vs 11.0%) or deceased (2.8% vs 1.6%). Patients with diagnosed malnutrition displayed a similar pattern for charges ($11,587 vs $10,969), and discharge to home (14.5% vs 18.8%), hospital (13.5 vs 11.1%) or deceased (2.8% vs 1.6%). Length of SNF stay did not differ between patients with and without PIs (18.5 vs 18.6) and was slightly shorter for patients with diagnosed malnutrition (17.3 vs 18.9). While higher probability of rehospitalization or death could impact these results, drivers behind these differences need further investigation. Because malnourished patients were more likely to have PIs and both PI and malnutrition are associated with poorer patient discharge outcomes and higher costs, efforts to identify malnutrition and implement proper nutrition interventions should be prioritized as part of SNF quality improvement initiatives.

The Relationship Between Knee Pain and Heart Failure in Older Black and Latino Women

Background: Knee pain is the second-most prevalent and disabling common pain condition globally, having deleterious effects on daily function including mobility and exercise capacity; chronic knee pain is especially prevalent in older adults. There is substantial evidence to indicate that physically inactive individuals have higher rates of cardiovascular disease. Nonetheless, studies investigating cardiovascular risks with osteoarthritis have had mixed results. Objective: This study explores the relationship between knee pain and heart failure especially examining the factors of age, gender, race in U.S. older adults. Methods: Retrospective secondary analysis of Medicare claims data for 1.478 million adults over age 65. The standard analytical file for 2017 was segmented according to the presence of any of several ICD-10 codes for heart failure (HF). Medicare beneficiaries with and without HF diagnoses were evaluated for knee pain and other common pain-associated conditions; pain condition data was stratified by age, gender and race codes. Results: Knee pain was markedly increased in women with HF in the 65-70- and 70–75-year-old age-cohorts and relatively less increased in older age-cohorts and males. Knee pain in women was especially elevated in those with Medicare race codes indicating Black and Hispanic status. Conclusion: in a large cohort of Medicare beneficiaries, knee pain was noted to be markedly increased in younger cohorts of older women with HF, and more prevalent in Black and Hispanic women. Further studies should evaluate lifestyle, biomechanics, and inflammatory factors that may be contributing to this relationship.

Impact of hospital quality on surgical outcomes in patients with high social vulnerability: Association of textbook outcomes and social vulnerability by hospital quality

BackgroundWe sought to define the impact of high- versus low-quality hospitals on the risk of adverse outcomes among patients undergoing hepatopancreatic surgery relative to social vulnerability. Social vulnerability is an important factor associated with risk of adverse postoperative outcomes. MethodsPatients from 2013 to 2017 were identified from the Medicare Inpatient Standard Analytic File. Hospital quality was determined by calculating risk-adjusted probability to achieve a textbook outcome. The Social Vulnerability Index was used to categorize patients. Risk-adjusted probability of mortality, morbidity, and textbook outcome was examined across varying social vulnerability indices stratified by low-, average-, and high-quality hospitals. ResultsAmong 27,000 patients who underwent a pancreatectomy (67%) or hepatectomy (33%%), median patient age was 72 years, 48% were female, and 89% were White; mean Social Vulnerability Index was 49. Risk-adjusted 90-day mortality (odds ratio: 1.32, 95% CI: 1.20–1.59, P = .004) and postoperative complications (odds ratio: 1.12, 95% confidence interval: 1.00–1.24, P = .044) were both higher among beneficiaries from the highest social vulnerability counties versus the lowest counties. At low-quality hospitals, patients from the highest vulnerability counties had 70% higher odds of mortality (odds ratio: 1.70, 95% confidence interval: 1.16–2.48, P = .007), 31% higher odds of overall morbidity odds ratio: 1.31, 95% confidence interval: 1.05–2.63, P = .013), and 19% lower odds of achieving a textbook outcome (odds ratio: 0.81, 95% confidence interval: 0.66–0.99, P = .035)—all of which were markedly worse compared with outcomes achieved at high-quality hospitals. ConclusionAmong patients with increased social vulnerability, outcomes were considerably better at high-quality hospitals. Referral of socially vulnerable patients to high-quality hospitals represents an important opportunity to ensure optimal outcomes after complex surgery.

Unicompartmental knee arthroplasty: A PearlDiver study evaluating complications rates, opioid use and utilization in the Medicare population

PurposeDespite increased utilization of unicompartmental knee arthroplasty (UKA) for unicompartmental knee osteoarthritis, outcomes in Medicare patients are not well-reported. The purpose of this study is to analyze practice patterns and outcome differences between UKA and TKA in the Medicare population. It is hypothesized that UKA utilization will have increased over the course of the study period and that UKA will be associated with reduced opioid use and lower complication rates compared to TKA.MethodsUsing PearlDiver, the Humana Claims dataset and the Medicare Standard Analytic File (SAF) were analyzed. Patients who underwent UKA and TKA were identified by CPT codes. Postoperative complications were identified by ICD-9/ICD-10 codes. Opioid use was analyzed by the number of days patients were prescribed opioids postoperatively. Survivorship was defined as conversion to TKA.ResultsIn the Humana dataset, 7,808 UKA and 150,680 TKA patients were identified. 8-year survivorship was 87.7% (95% CI [0.861,0.894]). Postoperative opioid use was significantly higher after TKA (186.1 days) compared to UKA (144.7 days) (p < 0.01, Δ = 41.1, 95% CI = [30.41, 52.39]). In the SAF dataset, 20,592 UKA patients and 110,562 TKA patients were identified. Survivorship was highest in patients > 80 years old and lowest in patients < 70 years old. In both datasets, postoperative complication rates were higher in TKA patients compared to UKA patients in nearly all categories.ConclusionsUKA represents an increasingly utilized treatment for osteoarthritis in the Medicare population and may be comparatively advantageous to TKA due to reduced opioid use and complication rates after surgery.Level of evidenceLevel III

Reoperation Rates and Disease Costs for Primary Open-Angle Glaucoma Patients in the United States Treated with Incisional Glaucoma Surgery

To evaluate the claims-based 5-year economic and reintervention burden for patients with primary open-angle glaucoma (POAG) after incisional glaucoma surgery in the United States. Retrospective Medicare claims analysis. One thousand nine hundred forty-five Medicare fee-for-service patients with POAG treated with trabeculectomy, tube shunt, or EX-PRESS shunt procedures from 2010 through2011. Patients with POAG treated with incisional glaucoma surgery (trabeculectomy, tube shunt, or EX-PRESS shunt) from 2010 through 2011 were identified in the Medicare 5% Standard Analytical Files. Ten years of claims data for each patient (2005-2016) were evaluated for prior incisional surgeries and downstream procedures in the treated eye within 5 years of index. Patients' characteristics, downstream procedures, and POAG-related costs were evaluated. Proportions of patients with downstream procedures in the index eye indicating failure of the index surgery, glaucoma reoperations, nonfailure complications, interventions, or cataract surgery were assessed over 5 years of follow-up. Cumulative rates of index surgery failure and glaucoma reoperations over 5 years after incisional glaucoma surgery. Of 1945 patients, 223 underwent EX-PRESS shunt, 551 underwent tube shunt, and 1171 underwent trabeculectomy at index. Rates of failure, glaucoma reoperations, or nonfailure complications rose over 5 years after index for all patient subgroups. At 1 year, 15.1% of EX-PRESS shunt patients, 11.6% of tube shunt patients, and 8.8% of trabeculectomy patients had experienced failure based on postindex procedures. By 5 years follow-up, these rates were 31.5% of EX-PRESS shunt patients, 27.1% of tube shunt patients, and 23.5% of trabeculectomy patients. Five-year rates of glaucoma reoperations were 18.3%, 14.0%, and 15.1%, respectively. Among tube shunt and trabeculectomy patients with prior incisional surgery, the 5-year failure rates were 32.5% and 32.6%, and reoperations rates were 12.0% and 26.1%, respectively. More than one-fourth of patients with POAG treated with incisional surgery underwent additional procedures to address index surgery failure within 5 years. Of these, more than half underwent additional incisional glaucoma surgery. These outcomes from clinical practice settings demonstrate that patients with POAG who require incisional surgery continue to need additional safe and effective surgical treatment options to manage their glaucoma.

Hepatic macrosteatosis in the US pediatric deceased liver donor population.

The pediatric obesity epidemic is associated with early development of hepatic macrosteatosis, a hallmark of non-alcoholic fatty LI disease, which is thought to be more rapidly progressive in children than adults. Macrosteatosis in adult allografts is associated with allograft loss, but this has not been examined in pediatric donors. We studied all pediatric potential whole LI donors (2005-2018) who had a LI biopsy in the SRTR (n=862) and whose LI was transplanted (n=862). Macrosteatosis was abstracted from biopsy reports and compared to values in the SRTR standard analytic file. Recipients of macrosteatotic pediatric allografts were matched 1:1 to recipients of non-macrosteatotic pediatric allografts by propensity score matching on donor/recipient variables. All-cause allograft loss was estimated via Kaplan-Meier analysis and Cox proportional hazards model. From 2005 to 2018, the proportion of pediatric donors (age ≥2years) with obesity increased (14.8% to 21.7%; p<.001), as did the proportion of pediatric deceased whole LI-only donor allografts with macrosteatosis (n=10648; 1.8% to 3.9%; p<.001). The median degree of macrosteatosis among macrosteatotic donors was 10% (IQR 5-30). There were no significant differences in all-cause allograft loss between recipients of pediatric LI allografts with and without macrosteatosis at 90days (p=.11) or 1year (p=.14) post-transplant in Kaplan-Meier analysis or a Cox proportional hazards model (p>.05). Obese pediatric LI donors have increased over time and were more likely to have hepatic macrosteatosis; however, pediatric macrosteatosis did not appear to adversely affect recipient outcomes.

Social vulnerability and fragmentation of postoperative surgical care among patients undergoing hepatopancreatic surgery

BackgroundRegionalization of hepatopancreatic surgery to high-volume hospitals has been associated with fragmentation of postoperative care and, in turn, inferior outcomes after surgery. The objective of this study was to examine the association of social vulnerability with the likelihood of experiencing fragmentation of postoperative care (FPC) after hepatopancreatic surgery. MethodsPatients who underwent hepatopancreatic surgery and had at least 1 readmission within 90 days were identified using Medicare 100% Standard Analytical Files between 2013 and 2017. Fragmentation of postoperative care was defined as readmission at a hospital other than the index institution where the initial surgery was performed. The association of social vulnerability index and its components with fragmentation of postoperative care was examined. ResultsAmong 11,142 patients, 8,053 (72.3%) underwent pancreatectomy, and 3,089 (27.7%) underwent hepatectomy. The overall incidence of fragmentation of postoperative care was 32.9% (n = 3,667). Patients who experienced fragmentation of postoperative care were older (73 years [interquartile range: 69–77]FPC vs 72 years [interquartile range: 68–77]non-FPC) and had a higher Charlson comorbidity score (4 [interquartile range: 2–8]FPC vs 3 [interquartile range: 2–8]non-FPC) (both P < .001). Median overall social vulnerability index was higher among patients who experienced fragmentation of postoperative care (52.5 [interquartile range: 29.3–70.4]FPC vs 51.3 [interquartile range: 27.9–69.4]non-FPC, P = .02). On multivariable analysis, the odds of experiencing fragmentation of postoperative care was higher with increasing overall social vulnerability index (odds ratio: 1.14; 95% confidence interval 1.01–1.30). Additionally, the odds of experiencing fragmentation of postoperative care were higher among patients with high vulnerability owing to their socioeconomic status (odds ratio: 1.28; 95% confidence interval 1.12–1.45) or their household composition and disability (odds ratio: 1.35; 95% confidence interval 1.19–1.54), whereas high vulnerability owing to minority status and language was inversely associated with fragmentation of postoperative care (odds ratio: 0.73; 95% confidence interval 0.64–0.84). ConclusionSocial vulnerability was strongly associated with the odds of experiencing fragmented postoperative care after hepatopancreatic surgery.

205. Cervical myelopathy increases cost of care and length of stay following hip fracture

<h3>BACKGROUND CONTEXT</h3> Hip fractures are devastating injuries for the elderly and an increasing burden to the health care system. Cervical myelopathy, as a common cause of disability, instability, and falls in this population, places patients at risk for hip fracture, and myelopathic patients are associated with increased complications after hip surgery. The precise co-prevalence of cervical myelopathy with hip fractures, as well as its impact on the health care system, however, have yet to be described. <h3>PURPOSE</h3> This study sought to determine the prevalence of cervical myelopathy among hip fracture patients and hypothesized that myelopathic hip fracture patients were associated with greater medical complexity and per-patient costs. <h3>STUDY DESIGN/SETTING</h3> Retrospective database review. <h3>PATIENT SAMPLE</h3> All Medicare beneficiaries from 2005-2012. <h3>OUTCOME MEASURES</h3> Average patient charges/payment; length of admission. <h3>METHODS</h3> In this Institutional Review Board-exempt study, Medicare patients between 2005 and 2012 were reviewed using the Medicare Standard Analytical Files with the PearlDiver Patient Records Database (PearlDiver technologies, Inc., Colorado Springs, CO). International Classification of Diseases, Ninth Revision, (ICD-9) diagnosis codes were used to identify patients with hip fractures and cervical myelopathy. Myelopathic hip fracture patients were compared with non-myelopathic hip fracture patients with regard to age, medical comorbidities, average charges/payment per patient, and length of inpatient admission. Myelopathic patients who underwent cervical decompression after hip fractures were also identified using Current Procedural Terminology (CPT) codes, and average charges/payment per patient and length-of-stay calculated. Statistical analysis with t-test and Chi-squared test was performed, with statistical significance set at p<0.05. <h3>RESULTS</h3> A total of 2,309,972 hip fracture patients from 2005-2012 were identified. Only a small fraction of this cohort carried a diagnosis of cervical myelopathy (22,884; 1.0%) compared with non-myelopathic hip fracture patients (2,287,088; 99%). Myelopathic hip fracture patients were significantly younger (p<0.001) but were also associated with significantly greater incidence of hypertension, coronary artery disease, stroke, obesity, tobacco use, diabetes, and osteoporosis (p<0.001) than their non-myelopathic counterparts. Myelopathic hip fracture patients were associated with significantly greater average charges/payments per patient ($63,694/$15,595 myelopaths vs $38,043/$9,778 non-myelopaths; p<0.001) and longer length of stays associated with their non-myelopathic counterparts (myelopaths: 6.7 days; non-myelopaths: 6.4 days; p<0.001). Spine surgery for myelopathy following hip fracture was rare; only a small proportion of myelopathic hip fracture patients went on to have cervical decompression after their injury (487 patients; 2.1%). <h3>CONCLUSIONS</h3> Hip fracture patients with cervical myelopathy carry significantly more medical comorbidities than their non-myelopathic counterparts and, despite being a small fraction of the overall hip fracture population, incur significantly greater costs and longer admissions. Cervical decompression following hip fracture is infrequent, likely relating to the challenging prognoses of these patients. These results highlight the complexity of myelopathic patients, and early treatment of cervical myelopathy should be considered an important part of hip fracture prevention strategies. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

A matched-control study on the effects of depressive disorders following open reduction and internal fixation for acetabular fractures.

The World Health Organization (WHO) postulates that depressive disorders (DD) will be the leading cause of morbidity and mortality by 2030. Studies evaluating the association of DD following open reduction and internal fixation (ORIF) for the treatment of acetabular fractures are limited. Therefore, the purpose of this matched-control study was to determine whether DD patients undergoing ORIF for acetabular fractures have higher rates of: (1) in-hospital lengths of stay (LOS); (2) readmissions; (3) medical complications; and (4) costs of care. A retrospective query from the 100% Medicare Standard Analytical Files (SAF) was performed to identify patients who underwent ORIF for acetabular fractures. The study group consisted of those patients with DD, whereas patients without the condition served as controls. Primary endpoints of the study were to compare in-hospital LOS, readmission rates, ninety-day medical complications, and costs of care. A p-value less than 0.01 was considered statistically significant. The query yielded 7084 patients within the study (ORIF = 1187, control = 5897). DD patients were found to have significantly longer in-hospital LOS (11 days vs. 10 days, p < 0.0001); however, odds (OR) of readmission rates were similar (23.16 vs. 18.68%; OR: 0.91, p = 0.26). Multivariate regression demonstrated DD to be associated with significantly higher (67.69 vs. 25.54%; OR: 2.64, p < 0.0001) 90-day medical complications. DD patients had significantly higher day of surgery ($30,505.93 vs. $28,424.85, p < 0.0001) and total global 90-day costs ($41,721.98 vs. $37,330.16, p < 0.0001) of care. After adjusting for covariates, DD is associated with longer in-hospital, complications, and costs of care in patients undergoing ORIF for the treatment of acetabular fractures, whereas readmission rates are similar. The study is vital as it can be used by orthopaedists and healthcare professionals to adequately educate these patients of the potential outcomes following their surgical procedure.

Variation in outcomes across surgeons meeting the Leapfrog volume standard for complex oncologic surgery.

A large body of evidence supports regionalization of complex oncologic surgery to high-volume surgeons at high-volume hospitals. However, whether there is heterogeneity of outcomes among high-volume surgeons at high-volume hospitals remains unknown. Patients who underwent esophagectomy, lung resection, pancreatectomy, or proctectomy for primary cancer were identified within the Medicare 100% Standard Analytic File (2013-2017). Mixed-effects analyses assessed the association between Leapfrog annual volume standards for surgeons (esophagectomy ≥7, lung resection ≥15, pancreatectomy ≥10, proctectomy ≥6) and hospitals (esophagectomy ≥20, lung resection ≥40, pancreatectomy ≥20, proctectomy ≥16) relative to postoperative complications and 90-day mortality. Additional analyses using New York's all-payer Statewide Planning and Research Cooperative System (2004-2015) were performed. Among 112,154 Medicare beneficiaries, high-volume surgeons at high-volume hospitals were associated with lower adjusted odds of complications (esophagectomy: odds ratio [OR], 0.73 [95% CI, 0.61-0.86]; lung resection: OR, 0.88 [95% CI, 0.82-0.94]; pancreatectomy: OR, 0.73 [95% CI, 0.66-0.80]; proctectomy: OR, 0.92 [95% CI, 0.85-0.99]) and 90-day mortality (esophagectomy: OR, 0.60 [95% CI, 0.44-0.76]; lung resection: OR, 0.82 [95% CI, 0.73-0.93]; pancreatectomy: OR, 0.66 [95% CI, 0.56-0.76]; proctectomy: OR, 0.74 [95% CI, 0.65-0.85]). For the average patient at the average high-volume hospital, there was a 2-fold difference in the adjusted complication rate between the best-performing and worst-performing high-volume surgeon for all operations (esophagectomy, 28%-55%; lung resection, 7%-21%; pancreatectomy, 16%-35%; proctectomy, 16%-28%). Wide variation was also present in adjusted 90-day mortality for esophagectomy (3.5%-9.3%). Results from New York's all-payer database were similar. Even among high-volume surgeons meeting the Leapfrog volume standards, wide variation in postoperative outcomes exists. These findings suggest that volume alone should not be used as a quality indicator, and quality metrics should be continuously evaluated across all surgeons and hospital systems. Previous studies have demonstrated a surgical volume-outcome relationship for high-risk operations-that is high-volume surgeons and hospitals that perform a specific surgical procedure more frequently have better outcomes for that operation. Although most high-volume surgeons had better outcomes, this study demonstrated that some high-volume surgeons did not have better outcomes. Therefore, volume is an important factor but should not be the only factor considered when assessing the quality of a surgeon and a hospital for cancer surgery.

How does sleep apnea impact outcomes following primary total hip arthroplasty for femoral neck fractures: a matched-control analysis.

Cross-sectional studies have demonstrated that the prevalence of sleep apnea (SA) to be increasing within the United States. While studies have shown the association of SA and its association on complications following elective orthopedic procedures, well-powered studies investigating its impact in a traumatic setting are limited. The purpose of this study was to determine whether SA patients undergoing primary total hip arthroplasty (THA) for femoral neck fractures have higher rates of: (1) hospital lengths of stay (LOS); (2) readmissions; (3) complications; and (4) healthcare expenditures. The 100% Medicare Standard Analytical Files was queried from 2005 to 2014 for patients who sustained femoral neck fractures and were treated with primary THA. The study group consisted of patients with concomitant diagnoses of SA, whereas patients without SA served as controls. Study group patients were matched to controls in a 1:5 ratio by age, sex, and various comorbid conditions. Demographics of the cohorts were compared using Pearson's chi-squared analyses, and multivariate logistic regression analyses were used to calculate the odds (OR) of the effects of SA on postoperative outcomes. A p value less than 0.006 was considered to be statistically significant. The final query yielded 24,936 patients within the study (n = 4166) and control (n = 20,770) cohorts. SA patients had significantly longer in-hospital LOS (6 vs. 5days, p < 0.0001) but similar readmission rates (24.12 vs. 20.50%; OR: 1.03, p = 0.476). SA patients had significantly higher frequency and odds of developing medical complications (72.66 vs. 43.85%; OR: 1.57, p < 0.0001), and higher healthcare costs ($22,743.79 vs. $21,572.89, p < 0.0001). SA is associated with longer in-hospital LOS, higher rates of complications and healthcare expenditures. This study is vital as it can allow orthopaedists to educate patients with SA on the potential complications which may occur following their procedure. III.

Impact of Perioperative Thromboembolic Complications on Future Long-term Risk of Venous Thromboembolism among Medicare Beneficiaries Undergoing Complex Gastrointestinal Surgery

BackgroundVenous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), represents a common cause of morbidity and mortality following complex gastrointestinal surgery. Whether perioperative VTE also exposes patients to a higher long-term risk of VTE events remains poorly defined. MethodsThe Medicare 100% Standard Analytic Files were used to identify patients undergoing esophageal, hepatic, pancreatic, and colorectal resection between 2013 and 2017. The impact of perioperative VTE, defined as a VTE episode occurring during the index hospitalization or within 30 days of discharge, on the risk of developing subsequent long-term VTE episodes (i.e., more than 30 days following discharge) was examined. ResultsAmong 253,212 patients who underwent complex gastrointestinal surgery, 1.9% (n=4763) developed a VTE episode perioperatively. With a median follow-up period of 553 days (IQR 194–1052), a total of 11,052 patients (4.4%) developed a long-term VTE episode. Of note, patients who developed a DVT perioperatively had a higher risk of experiencing a long-term VTE episode than patients who had no perioperative thromboembolic complications (HR 6.50, 95%CI 6.04–6.98). The increase in risk was more pronounced among patients who had a PE (HR 27.97, 95%CI 25.39–30.80) at the time of surgery. Risk factors for long-term thromboembolic events following complex GI surgery included Black patients (HR 1.20, 95%CI 1.11–1.30), receipt of surgery at a teaching hospital (HR 1.09, 95%CI 1.04–1.13), nonelective surgery (HR 1.19, 95%CI 1.14–1.24), as well as a diagnosis of cancer (HR 1.10, 95%CI 1.05–1.16). The development of a perioperative DVT was associated with an increased long-term risk of VTE in both cancer (HR 5.59, 95%CI 5.29–6.61) and non-cancer patients (HR 6.98, 95%CI 6.37–7.64). Similarly, experiencing a PE at the time of surgery led to a higher long-term risk of VTE in cancer (HR 24.30, 95%CI 21.08–28.02), as well as non-cancer (HR 30.81, 95%CI 27.01–35.15) patients. ConclusionsPatients with a history of perioperative VTE had a higher risk of developing subsequent VTE events within 1–2 years following complex GI surgery. The risk was more pronounced among patients who had perioperative PE rather than DVT. These findings were consistent among both cancer and non-cancer patients.

Increased Reimbursement for Surgical Fixation of Hip Fractures: The Difference Between the Hospital and the Surgeon.

To evaluate trends and variations in hospital charges and payments relative to surgeon charges and payments for surgical treatment of hip fractures in the US Medicare population. Hospital and surgeon charges and payments after treatment of hip fractures by closed reduction and percutaneous pinning (CRPP), open reduction internal fixation (ORIF), or intramedullary nail (IMN), along with corresponding patient demographics, 90-day and 1-year mortality, Charlson Comorbidity Index (CCI), and length of stay (LOS) from 2005 to 2014 were captured from the 5% Medicare Standard Analytic Files. The ratio of hospital to surgeon charges (CM: Charge Multiplier) and the ratio of hospital to surgeon payments (PM: Payment Multiplier) were calculated for each year and region of the United States and trended over time. Correlations between the CM and PM and LOS were evaluated using a Pearson correlation coefficient (r). Three thousand twenty-eight patients who underwent CRPP and 25,341 patients who underwent ORIF/IMN were included. The CM for CRPP increased from 10.1 to 15.6, P < 0.0001. The CM for ORIF/IMN increased from 11.9 to 17.2, P < 0.0001. The PM for CRPP increased from 15.1 to 19.2, P < 0.0001. The PM for ORIF/IMN increased from 11.5 to 17.4, P < 0.0001. Hospital charges and payments have continually increased relative to surgeon charges and payments for treatment of hip fractures despite decreasing LOS.

Profiles in social vulnerability: The association of social determinants of health with postoperative surgical outcomes

BackgroundThe association of different social vulnerability subthemes (ie, socioeconomic status, household composition and disability, minority status and language, and housing and transportation) with surgical outcomes remains poorly defined. The current study aimed to identify distinct profiles of social vulnerability among Medicare beneficiaries and define the association of these profiles with postoperative outcomes. MethodsThe Medicare 100% Standard Analytic Files were used to identify patients undergoing lung resection, coronary artery bypass grafting, abdominal aortic aneurysm repair, and colectomy between 2013 and 2017. A cluster analysis was performed based on ranked scores across the 4 subthemes of the Centers for Disease Control and Prevention social vulnerability index. The likelihood of complications, extended length of stay, readmission, and mortality were assessed relative to cluster vulnerability profiles. ResultsAmong 852,449 Medicare beneficiaries undergoing surgery, median social vulnerability index among patients in the cohort was 49 (interquartile range: 24–74); cluster analysis revealed 5 vulnerability profiles that had heterogeneity in the vulnerability subthemes, even among patients with similar overall social vulnerability index scores. Postoperative outcomes differed across the 5 vulnerability profiles, with patients in the profiles characterized by higher overall vulnerability having worse postoperative outcomes. In particular, risk of complications (profile 1, 31.9% vs profile 5, 34.0%), extended length of stay (profile 1, 21.7% vs profile 5, 24.3%), 30-day readmission (profile 1, 12.6% vs profile 5, 13.2%), and 30-day mortality (profile 1, 4.0% vs profile 5, 4.7%) was greater among patients with the highest vulnerability (all P < .01). Of note, surgical outcomes varied among patients who resided in communities with similar average social vulnerability index scores (social vulnerability index 49–54). In particular, patients in social vulnerability profile 4 had 26% increased odds of 30-day mortality compared to social vulnerability profile 2 patients (odds ratio 1.26, 95% confidence interval 1.21–1.30). Additionally, profile 3 patients had 15% higher odds of 30-day mortality versus profile 2 patients (odds ratio 1.15, 95% confidence interval 1.10–1.20). ConclusionPostoperative outcomes differed across patients based on cluster vulnerability profiles. Despite similar overall aggregate social vulnerability index scores, cluster analysis was able to discriminate various social determinants of health subthemes among patients who resided in “average” vulnerability communities that stratified patients relative to risk of adverse postoperative events.

Emergency Department Utilization Following Hepatopancreatic Surgery Among Medicare Beneficiaries

BackgroundCare delivered in hospital-based emergency departments (ED) is a target for cost savings. ED utilization following hepatopancreatic surgery remains poorly defined. We sought to define the rate of ED utilization following liver and pancreatic resection, as well as to identify factors associated with ED visits post-discharge. MethodsThe Medicare 100% Standard Analytic Files were used to identify Medicare beneficiaries who underwent hepatectomy or pancreatectomy between 2013 and 2017. Claims associated with ED services were identified using the relevant Revenue Center Codes. Patient characteristics and postoperative outcomes associated with ED care within 30 days of discharge were investigated. ResultsAmong 37,707 patients who underwent hepatopancreatic surgery, 10,323 (27.4%) had at least one ED visit within 30 days of discharge. Patients presenting to the ED were more likely to be male (OR 1.13, 95%CI 1.07–1.18). Patients undergoing a pancreatectomy (OR 1.39, 95%CI 1.32–1.47), as well as patients who had a perioperative complication (OR 1.16, 95%CI 1.10–1.23) and patients not discharged home (OR 1.41, 95%CI 1.33–1.49), were more likely to require ED care. In contrast, patients undergoing resection for cancer or surgery for an elective basis were less likely to present to the ED postoperatively (OR 0.92, 95%CI 0.87–0.97 and OR 0.22, 95%CI 0.20–0.23, respectively). Patients often had multiple ED visits within 30 days of discharge as 37.2% of patients presented to the ED with at least 2 visits. Visits were also most common in the immediate postoperative period, with 30.9% of ED visits taking place in the first 2 days from discharge. Among patients requiring postoperative ED care, 53.9% were readmitted within 30 days. ConclusionMore than 1 in 4 patients undergoing hepatopancreatic surgery presented to the ED within 30 days of discharge, with most patients returning to the ED within the first week of discharge. A subset of patients had multiple ED visits. Future efforts should target patients most likely to be high ED utilizers to avoid the need for early post-discharge ED use.

Association of County-Level Racial Diversity and Likelihood of a Textbook Outcome Following Pancreas Surgery.

IntroductionResidential racial desegregation has demonstrated improved economic and education outcomes. The degree of racial community segregation relative to surgical outcomes has not been examined.Patients and MethodsPatients undergoing pancreatic resection between 2013 and 2017 were identified from Medicare Standard Analytic Files. A diversity index for each county was calculated from the American Community Survey. Multivariable mixed-effects logistic regression with a random effect for hospital was used to measure the association of the diversity index level with textbook outcome (TO).ResultsAmong the 24,298 Medicare beneficiaries who underwent a pancreatic resection, most patients were male (n = 12,784, 52.6%), White (n = 21,616, 89%), and had a median age of 72 (68–77) years. The overall incidence of TO following pancreatic surgery was 43.3%. On multivariable analysis, patients who resided in low-diversity areas had 16% lower odds of experiencing a TO following pancreatic resection compared with patients from high-diversity communities (OR 0.84, 95% CI 0.72–0.98). Compared with patients who resided in the high-diversity areas, individuals who lived in low-diversity areas had higher odds of 90-day readmission (OR 1.16, 95% CI 1.03–1.31) and had higher odds of dying within 90 days (OR 1.85, 95% CI 1.45–2.38) (both p < 0.05). Nonminority patients who resided in low-diversity areas also had a 14% decreased likelihood to achieve a TO after pancreatic resection compared with nonminority patients in high-diversity areas (OR 0.86, 95% CI 0.73–1.00).ConclusionPatients residing in the lowest racial/ethnic integrated counties were considerably less likely to have an optimal TO following pancreatic resection compared with patients who resided in the highest racially integrated counties.Supplementary InformationThe online version contains supplementary material available at 10.1245/s10434-021-10316-3.

Comparison of patient demographics and patient-related risk factors for dislocations following reverse shoulder arthroplasty

BackgroundDislocations following primary reverse total shoulder arthroplasty (rTSA) are a feared and concerning complication. With the increasing number of reverse total shoulder arthroplasty (rTSA) procedures being performed worldwide e, studies evaluating risk factors for dislocation following this procedure are limited. The purpose of this study was to utilize a large claims database to identify patient-related risk factors associated with dislocations following primary rTSA. MethodsA retrospective query of the Part A and Part B 100% Medicare Standard Analytical Files (SAF) claims database was performed identifying patients who underwent primary rTSA for the treatment of glenohumeral osteoarthritis. The inclusion criteria for the study group consisted of all patients who had a dislocation within 2-years following the index procedure. Patients with a record of other arthroplasty-type procedures were excluded. The query yielded 30,670 patients with (n = 703) and without (n = 29,967) dislocations. Multivariate binomial logistics regression analysis was performed to calculate odds (OR) on the impact of patient-related risk factors for dislocations following primary rTSA. A P value less than .002 was considered statistically significant. ResultsStudy group patients that sustained a dislocation following primary rTSA were generally younger than the age of 65 (16.8 vs. 8.3%) and male (59.6 vs. 38.8%). Study group patients had a higher comorbidity burden, as demonstrated by higher mean Elixhauser-Comorbidity Index (ECI) scores (9 vs. 6, P < .0001). The greatest risk factors for dislocations included being male (OR: 3.06, P < .0001), opioid use disorder (OR: 1.74, P = .0007), hypertension (OR: 1.56, P = .001), morbid obesity (OR: 1.43, P < .0001), electrolyte and fluid derangements (OR: 1.29, P = .0001), and depressive disorders (OR: 1.23, P = .0001). ConclusionAs the number of primary rTSA procedures increase worldwide, identification of patient-related risk factors for dislocations is of great importance. The study showed the greatest risk factors for dislocations included male sex with modifiable risk factors being opioid use disorder, hypertension, and morbid obesity. The study is vital as it can facilitate in guiding orthopedists and altering management for these high-risk patients. Level of evidenceLevel III, retrospective comparative study.

Rural hospitals are not associated with worse postoperative outcomes for colon cancer surgery.

We sought to determine whether colorectal cancer surgery can be done safely at rural hospitals. The current study compared outcomes among rural patients who underwent colon resection at rural and nonrural hospitals. Medicare beneficiaries who underwent colon resection for cancer between 2013 and 2017 were identified using the Medicare Inpatient Standard Analytic Files. Patients and hospitals were designated as rural based on rural-urban continuum codes. Risk-adjusted postoperative outcomes and hospitalization spending were compared among patients undergoing resection at rural versus nonrural hospitals. Among 3,937 patients who resided in a rural county and underwent colon resection for cancer, mean age was 76.3 (SD: 7.1) years and 1,432 (36.4%) patients underwent operative procedure at a rural hospital. On multivariable analyses, no differences in postoperative outcomes were noted among Medicare beneficiaries undergoing colon resection for cancer at nonrural versus rural hospitals. Specifically, the risk-adjusted probability of experiencing a postoperative complication at a nonrural hospital was 15.4% (95% CI: 14.1%-16.8%) versus 16.3% (95% CI: 14.2%-18.3%) at a rural hospital (OR 1.08, 95% CI: 0.85-1.38); 30-day mortality (nonrural: 2.9%, 95% CI: 2.2-3.6 vs rural: 3.5%, 95% CI: 2.4-4.5) was also comparable. In addition, price standardized, risk-adjusted expenditures were similar at nonrural ($18,610, 95% CI: $18,037-$19,183) and rural ($19,010, 95% CI: $18,630-$19,390) hospitals. Among rural Medicare beneficiaries who underwent a colon resection for cancer, there were no differences in postoperative outcomes among nonrural versus rural hospitals. These findings serve to highlight the importance of policies and practice guidelines that secure safe, local surgical care, allowing rural clinicians to accommodate strong patient preferences while delivering high-quality surgical care.

Total shoulder arthroplasty (TSA) at United States News and World Report top-ranked hospitals in orthopedics – do rankings correlate with complications and cost?

IntroductionThe U.S. News & World Report (USNWR) hospital rankings remain the most publicly referenced system for identifying top hospitals for each specialty. The current study aims to evaluate whether there are any differences in outcomes and costs for patients undergoing anatomic TSA (ATSA) or reverse TSA (RTSA) for degenerative pathologies at ranked vs. non–ranked hospitals. MethodsThe 2011-2014 USNWR hospital rankings were used to identify ranked hospitals in “Orthopedics.” The 2011-2014 100% Medicare Standard Analytical Files (SAF100) were used to identify patients undergoing ATSA or RTSA for degenerative arthritis. The study cohort was divided into two groups, based on whether patients received surgery at a ranked hospital vs. a non–ranked hospital. Multi-variate logistic and linear regression analyses were used to assess for differences in 90-day outcomes and costs between ranked and non–ranked hospitals, while controlling for potential co-variates/confounders. ResultsA total of 82,417 TSA were included in the study – out of which 8,868 (10.8%) were performed in one of the 68 hospitals that were ranked by the USNWR between 2011 and 2014. Following adjustment for baseline demographics, and clinical characteristics, there were no statistically significant differences between ranked vs. non–ranked hospitals, with regards to rates of infectious complications (0.8% vs. 1.0%, OR 0.91 [95% CI 0.82-1.01]; P = .079), dislocations (0.8% vs. 0.9%, OR 1.07 [95% CI 0.79-1.43]; P = .658), peri-prosthetic fractures (0.3% vs. 0.3%, OR 0.77 [95% CI 0.47-1.21]; P = .269), pulmonary embolism (0.7% vs. 0.8%, OR 0.88 [95% CI 0.64-1.20]; P = .435), deep venous thrombosis (1.1% vs. 0.9%, OR 1.21 [95% CI 0.93-1.56]; P = .153), myocardial infarction (0.4% vs. 0.5%, OR 1.00 [95% CI 0.67-1.46]; P = .995), sepsis (6.0% vs. 7.3%, OR 0.95 [95% CI 0.85-1.05]; P = .314), urinary tract infections (4.8% vs. 5.6%, OR 0.99 [95% CI 0.87-1.11]; P = .831) and readmissions (7.1% vs. 8.3%, OR 0.91 [95% CI 0.82-1.01]; P = .079). Ranked hospitals, however, did have higher risk-adjusted charges (+ $6,167; P < .001), and costs (+ $1.831; P < .001) across the entire episode of care. ConclusionBased on our findings, patients undergoing TSA at ranked hospitals vs. non–ranked hospitals have similar outcomes, despite the former facilities having higher costs and charges across the episode of care. Level of EvidenceLevel III